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mtfjeCitpofi^ehJ^orfe 

College  of  ^tps^ieiang  anb  burgeons; 


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THE   STOMACH  AND  ABDOMEN 


THE  STOMACH  AND 
ABDOMEN 

FROM   THE   PHYSICIAN'S   STANDPOINT 

BY 

WILLIAM    RUSSELL,   M.D.,  LL.D. 

EX-PKESIDENT   ROYAL   COLLEGE   OF   PHYSICIANS,    EDINBURGH 

PROFESSOR-EMERITUS    OF   CLINICAL   MEDICINE,    EDINBURGH    UNIVERSITY 

CONSULTING    PHYSICIAN,    ROYAL   INFIRMARY,    EDINBURGH 

AUTHOR    OF    "arterial   SCLEROSIS,    HYPERTONUS,    AND    BLOOD    PRESSURE" 

AND  "  THE    SPHYGMOMETER  :     ITS    VALUE   IN    PRACTICAL   MEDICINE  " 


NEW    YORK 
WILLIAM    WOOD    AND    COMPANY 

MCMXXI 


PRINTED   IN   GREAT   BRITAIN 


i 
fit 


TO 
THOSE    BEYOND   THE   VEIL 

TO  WHOM  I  OWE  MUCH 
THIS  WORK  IS  DEDICATED 
IN     REVERENT    AFFECTION 


PREFACE 

In  submitting  this  work  to  the  medical  profession  some  words 
of  explanation  seem  to  be  necessary.  The  book  is  offered  as 
a  contribution  towards  the  elucidation  of  the  disorders  and 
diseases  of  the  stomach  and  other  abdominal  viscera  as  these 
have  to  be  dealt  with  by  the  family  practitioner,  and  by  the 
hospital  and  consulting  physician. 

The  writer  was  interested  in  these  matters  before  the  advent 
of  abdominal  surgery,  but  the  opening  of  that  epoch  gave  a 
motive  and  an  impetus  to  abdominal  diagnosis  which  had  pre- 
viously been  lacking.  That  diagnosis  could  be  tested  on  the 
operating  table,  instead  of  the  post-mortem-room  table  only, 
gave  a  significance  to  abdominal  diagnosis  which  had  been 
largely  wanting. 

As  a  teacher  in  a  great  medical  school,  and  as  a  physician 
to  a  great  general  hospital,  where  every  type  of  disorder  and 
disease  was  admitted  into  the  wards,  it  was  a  duty  and  a 
privilege,  not  only  to  treat  sick  people,  but  to  expound  to 
students  the  methods  and  the  steps  by  which  diagnosis  was 
reached,  and  on  which  treatment  was  based.  The  advent 
of  abdominal  surgery  opened  up  a  new  field  for  investigation, 
and  for  teaching  internal  diagnosis,  of  which  the  writer  took 
as  full  advantage  as  circumstances  allowed. 

As  time  passed,  and  experience  was  tested  and  re-tested, 
the  problems  became  simpler  and  the  points  essential  to 
correct  diagnosis  clearer.  This  led  to  simplification  in  teach- 
ing, and  this  book  represents  more  or  less  fully  the  position 
reached.  There  is  little  in  it  which  has  not  been  taught  and 
re-taught  by  the  writer  as  abdominal  cases  were  admitted  to 
his  wards.  Bits  of  clinical  lectures  and  bits  of  cliniques,  which 
were  written  from  time  to  time  as  new  light  arose,  have  been 


viii  PREFACE 

incorporated,  and  hence  a  certain  amount  of  repetition  has 
been  inevitable. 

The  records  of  cases  by  which  the  text  is  illustrated  have 
been  deliberately  restricted  in  number.  Those  which  have 
been  used  are  sometimes  of  recent  date,  at  other  times  of 
earlier  date  ;  they  are  used  to  illustrate  the  points  which  deter- 
mined diagnosis — a  diagnosis  which  in  many  of  the  cases  was 
checked  in  the  operating  room. 

It  is  the  hope  of  the  writer  that  the  book  may  be  found 
helpful  in  simplifying  the  problems  of  abdominal  diagnosis. 

WILLIAM    RUSSELL. 

Edinburgh, 
April,  192 1 


TABLE    OF    CONTENTS 


CHAPTER    I 


PAGE 


The    Relations    of    the    Practitioner    and    the   Physician    to 

AisDOMiNAL  Diagnoses     .......  ' 

CHAPTER    II 
Examination  of  the  Abdomen 5 


SECTION    L— THE   STOMACH 

CHAPTER    III 

Two  Classes  of  Primary  Disorder 8 

Iiilroductoiy.     Simplification  of  teaching. 

CHAPTER    IV 

Disorders  of  Chemical  Function  ;  that  is  of  Digestion.    Dimin- 
ished Secretion  of  Gastric  Juice,  or  Hypochlorhydria    .      12 

lutroductory:  the  relation  of  the  stomach  to  carbohydrate  and  protein 
food.  Diminished  secretion  of  gastric  juice  or  hypochlorhydria. 
Causes  of  diminished  secretion.  Clinical  investigation  and  symptoms. 
Illustrative  cases.  Complications  of  hypochlorhydria.  Treatment  of 
catarrh  and  dilatation  due  lo  hypochlorhydria.  Treatment  of  hypo- 
chlorhydria, 

CHAPTER  V 

Increased  Secretion  of  Gastric  Juice.   Hypersecretion  or  Hyper- 

chlorhydria 33 

Causation  and  pathology.  The  constitutional  factor  :  an  acid  dyscrasia. 
The  determining  causes  of  hypersecretion :  food,  alcohol,  tea  and 
coffee,  meat  extracts.  Symptoms ;  the  explanation  of  the  symptoms. 
An  acid  dyscrasia.  Other  immediate  determining  causes.  Additional 
comments.  Illustrative  cases :  (a)  acute,  (d)  longer  duration.  Com- 
plications;  pyloric  spasm  ;  atonicity  and  dilatation  ;  ptosis  ;  ulceration. 


TABLE   OF   CONTENTS 


CHAPTER   VI 

PAGE 

Air-Swallowing:  commonly  called  Flatulent  Dyspepsia    .         .       59 

Illustrative  cases.     Abdominal  rigidity  in  air-swallowing.     Attacks   of 
severe  cardiac  depression.     General  remarks.     Treatment. 


CHAPTER   VII 

Method  of  Determining  the  Position  and  Size  of  the  Stomach 

IN  the  Recumbent  Position  .......       68 

Percussion — tympanicity.  Auscultation  and  scratching.  Bulging  and 
peristalsis.  Palpation  and  splashing.  Succussion.  Auscultation- 
succussion.  The  right  border.  The  absence  of  physical  signs  of  general 
dilatation.  Explanation  of  absence  of  succussion  wave.  X-ray  exami- 
nation. The  right  border  in  the  recumbent  position  as  a  guide  to 
pyloric  or  duodenal  lesion. 


CHAPTER  VIII 
Dilatation  of  the  Stomach — two  Types 78 

CHAPTER    IX 

Gastroptosis,  or  Dislocation  of  the  Stomach      ....       82 

Definition.  Anatomical  considerations.  Symptoms.  Physical  exami- 
nation. Congenital  pyloric  stenosis  as  a  cause  of  gastroptosis.  Illus- 
trative cases.     Treatment, 

CHAPTER   X 

Pyloric  Stenosis,  especially  Congenital  Stenosis  in  the  Adult      97 

Pyloric  spasm.  Effect  of  pyloric  stenosis.  Congenital  stenosis  a  cause 
of  pyloric  obstruction  in  the  adult.  Congenital  hypertrophic  stenosis 
in  infants.  The  medical  position.  The  surgical  position.  The  exist- 
ence of  the  condition.  Cases.  Diagnosis:  symptoms ;  physical  exami- 
nation ;  pyloric  spasm  or  cramp ;  chemical  examination  of  gastric 
contents.  Summary.  Treatment.  The  clinical  pathology.  Further 
remarks  on  congenital  stenosis  and  cases. 


CHAPTER    XI 

Gastric  Ulcer 

Acute   or   recent   gastric    ulcer.  Pathogeny.      Preceding   conditions. 

Position  of  ulcer.     Symptoms.  Perforation.     Reservations  and  wrong 

diagnoses.     Gastric  ulcer  heals.  Treatment  of  acute  ulcer.     Chronic 
ulcer.     Illustrative  cases. 


117 


TABLE    OF   CONTENTS  xi 


CHAPTER   XII 

E   StOI 

Illustrative  cases  with  comments. 


PAGE 

Malignant  Disease  of  the  Stomach 133 


SECTION  IL— THE  PYLORUS  AND  DUODENUM 

CHAPTER   XIII 
Introductory    ...........     149 

Hyperchlorhydria.  Recurrence  of  attacks.  Pain  as  a  symptom.  The 
etiology  of  acute  ulcer.  Perforation.  Healing  of  acute  ulcer.  Pyloric 
and  duodenal  scar.  Hyperchlorhydria  and  gastric  atony.  Effect  of 
scar  and  narrowing.     Illustrative  cases. 

CHAPTER    XIV 
Duodenal  Ulcer 159 

Diagnosis :  pain ;  melaena.  Absence  of  melaena.  Persistent  pain  and 
sagging.  Symptoms  masked.  Illustrative  cases.  Causes  of  unsatisfac- 
tory operation  results  :  inefficient  drainage  ;  continued  haemorrhage  or 
pain ;  recurrence  of  hyperchlorhydria  or  appearance  of  hypochlor- 
hydria  ;  spastic  stomach. 

CHAPTER   XV 

Silent  or  Masked  Duodenal  Ulcer 170 

Pain  :  its  cause  and  its  control.     Cases. 


SECTION   III.— THE   INTESTINAL   TRACT 

CHAPTER   XVI 
Enteroptosis  :  Splanchnoptosis  or  Visceroptosis  .        .         .         .177 

Definitions.  Occurrence  in  both  sexes.  Ptosis  of  transverse  colon  : 
air-block.     Ptosis  of  hepatic  flexure.     Complications. 

CHAPTER   XVII 
Appendicitis 186 

Pathology,  diagnosis  and  indications  for  treatment.  Anomalous 
appendix  cases.  Cases  illustrating  wrong  diagnoses.  Conclusions  and 
summary. 


xii  TABLE   OF   CONTENTS 


CHAPTER   XVIII 

PAGE 

iNfESTiNAL  Obstruction:  Malignant  Disease  of  Rectum;   Entero- 

SPASM 212 

Illustrative  cases  and  comments. 


SECTION   IV.— THE   CESOPHAGUS 

CHAPTER   XIX 
The  oesophagus 228 

Obstruction.       Symptoms.       Etiology     and     diagnosis.       Treatment. 
Remarks. 


SECTION   v.— THE   LIVER 

CHAPTER   XX 
Jaundice  or  Icterus 233 

Definition.  Causes  or  varieties.  Catarrhal  jaundice :  causes  and 
treatment.  Obstruction  by  calculus.  Gall-stone  colic.  Passing  of 
small  stones.  Treatment.  Cholangitis  or  inflammation  of  bile  ducts. 
Cholecystitis  and  cholangitis  due  to  gall-bladder  calculi.  Treatment. 
Malignant  disease  of  head  of  pancreas.  Treatment.  Hypertrophic  or 
biliary  cirrhosis  of  liver.  New-growths  pressing  on  bile  duct.  New- 
growth  in  duodenum  at  mouth  of  duct.  Animal  parasites  leading  to 
obstruction.  Illustrative  cases.  General  considerations.  Gall-stone 
colic  without  jaundice.     Illustrative  cases.     Conclusion. 

CHAPTER   XXI 
The  CiRRHOSES  of  the  Liver 267 

CHAPTER    XXII 

Malignant  Disease  of  Liver 277 

Cases. 


SECTION   VI.— THE   SPLEEN 

CHAPTER    XXIII 

Enlargement:  Splenomegalv 280 

Cases  and  comments. 


TABLE   OF   CONTENTS  xiii 

SECTION   VII.— THE   KIDNEY 
CHAPTER    XXIV 

PAGE 

Introductory  :  Movable  Kidney.     Perinephric  Abscess       .        .     284 

Movable,  floating,  and  displaced  kidney.  Displaced  and  fixed  kidney. 
Symptoms.  Pathology.  Treatment.  Acute  perinephritis  with  abscess  ". 
Symptoms  ;  diagnosis  ;  treatment.     Cases. 

CHAPTER   XXV 

Renal  Calculus  and  Renal  Colic 292 

Symptoms.     Examination.     Illustrative  cases. 

CHAPTER   XXVI 
Enlargemknt  of  the  Kidneys 302 

Hydronephrosis  :  examination  and  diagnosis.  Pyonephrosis  :  cases  and 
diagnosis.     Neoplasm  :  cases  and  diagnosis.     The  right  kidney. 


CHAPTER   XXVII 
Bacillus  Coli  Infection  of  the  Urinary  Tract 
Illustrative  cases  and  treatment. 


324 


m: 


THE 

STOMACH  AND  ABDOMEN 

CHAPTER  I 

THE   RELATIONS   OF  THE   PRACTITIONER  AND   THE   PHYSICIAN 
TO   ABDOMINAL  DIAGNOSES 

In  some  quarters  it  has  been  thought  that  the  time  was  not 
far  distant  when  the  art  of  the  physician  would  become 
obsolete,  and  be  replaced  by  the  craft  of  the  surgeon.  If 
this  prediction  be  ever  realized,  the  fault  will  lie  at  the  door 
of  the  physician  and  of  the  general  practitioner.  The  latter, 
however  much  more  he  may  be,  ought  certainly  to  be  a 
physician,  for  to  be  a  successful  practitioner,  in  the  only  true 
sense,  requires  that  he  should  be  a  careful,  and,  as  far  as 
possible,  a  skilful  diagnostician.  In  no  region  has  a  more 
debatable  land  arisen  than  in  the  domain  of  abdominal 
disorder,  and  the  cause  of  this  is  to  be  found  in  the  following 
considerations. 

In  the  very  nature  of  things,  abdominal  disturbances 
come  into  the  hands  of  the  practitioner  and  the  physician. 
It  is  on  them  that  the  responsibility  of  diagnosis  must 
primarily  lie,  and  it  is  imperative  that  they  should  rise  to 
their  extended  responsibilities  in  this  department,  and 
devote  themselves  to  the  attainment  of  skill  in  the  differential 
diagnoses  of  abdominal  diseases.  That  a  gastric  condition 
may  require  a  surgical  operation  no  more  removes  it  from  the 
domain  of  the  practitioner  and  the  physician  than  the  diag- 
nosis of  an  empyema  lies  with  the  surgeon  because  he  is 
called  in  to  operate  on  it.  The  contrary  idea  is  but  an 
illustration  of  what  we  have  heard  a  good  deal  in  other 

I  I 


2  THE  STOMACH   AND   ABDOMEN 

affairs — the  want  of  clear  thinking.  The  physician  has 
above  all  else,  in  the  first  place,  to  be  a  diagnostician  ;  and 
the  position  assumed  in  some  quarters  that  he  is  not  to  be 
allowed  to  use  his  art  in  the  disorders  and  diseases  of-  the 
abdomen  is  as  amusing  as  it  is  astounding.  There  is  no 
doubt  that  the  opening  up  of  abdominal  surgery  has  made  it 
necessary  to  be  more  precise,  more  definite,  more  detailed  in 
diagnosis  than  formerly.  We  no  longer  ought  to  be  satisfied 
with  such  diagnoses  as  dyspepsia,  hsematemesis,  jaundice, 
colic,  intestinal  obstruction,  or  peritonitis  ;  and  the  physician 
ought  to  be  the  pioneer  in  that  whole  realm  of  diagnosis.  It 
is  on  him  that  the  onus  lies  of  indicating  the  paths  and 
methods  of  differential  diagnosis  in  the  abdomen,  as  he  has 
done  in  the  thorax  and  in  the  brain.  He  is  not  justified  in 
abandoning  his  birthright  in  internal  diagnosis.  Whatever 
difficulties  there  may  be,  or  appear  to  be,  they  have  to  be 
faced  and  solved.  Not  only  ought  he  to  be  a  pioneer  in 
differential  diagnosis,  but  he  ought  to  be  more,  for,  however 
much  the  surgeon's  craft  may  be  requisitioned  by  him,  he 
ought  to  know  as  well  as  the  surgeon  not  only  the  diseases 
which  require  operation,  but  also  the  kind  of  operation  that 
may  or  can  be  done  in  the  various  diseases  with  which  he  has 
to  deal. 

Surgery  is  not  an  occult  science,  even  such  questions  as 
the  advantages  of  anterior  or  posterior  gastro-enterostomy 
are  copiously,  not  to  say  openly,  discussed.  The  physician 
knows,  or  ought  to  know,  that  if  he  diagnoses  certain  con- 
ditions the  treatment  is  gastro-enterostomy,  although  he 
leaves  it  to  the  surgeon  to  select  the  method  ;  and  that,  if  he 
diagnoses  other  conditions,  they  are  not  worth  meddling  with 
unless  they  can  be  removed  entirely.  Sometimes  one  gets 
the  impression  that  the  physician  thinks  he  ought  not  even 
to  know  what  the  surgeon  will  do  in  any  particular  case, 
which  is  as  curious  an  affectation  as  if  he  professed  ignorance 
of  how  a  broken  leg  or  a  dislocated  shoulder  is  treated.  If 
the  physician  diagnoses  gall-stones,  he  knows  that  the  surgeon 
to  remove  them  has  to  use  the  knife ;  the  line  of  incision,  and 
whether  catgut  or  silk  be  used,  is  no  part  of  his  responsibility ; 


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THE  PHYSICIAN  AND  DIAGNOSIS  3 

but  it  is  absurd  to  affect  ignorance  of,  or  want  of  intelligent 
appreciation  of,  the  dexterity  and  skill  of  the  surgeon  in 
carrying  out  all  the  details  of  the  operation  and  the  after- 
healing  of  the  wound.  If  the  physician  is  confident  of  his 
diagnosis  he  will  not  usually  have  any  serious  difficulty  in 
convincing  his  surgical  confrere  that  operation  is  desirable. 

Difficulty  arises  more  frequently,  perhaps,  when  the 
surgeon  recommends  an  "  exploratory  "  operation,  and  the 
physician  does  not  agree  with  him.  The  "  exploratory  " 
operation  tends,  indeed,  to  be  so  widely  applied  and  advocated 
that  it  threatens  to  be  the  bane  of  differential  diagnosis. 
It  has  its  own  place,  but  when  it  becomes  the  screen  for 
careless,  ill-informed  opinion,  or  for  ignorance  of  methods,  it 
would  be  difficult  to  apply  too  damnatory  criticism  to  it. 

If  the  physician's  first  duty  is  diagnosis,  his  second  is  to 
know  enough  of  surgical  methods  and  of  surgical  successes 
to  understand  and  appreciate  what  he  recommends  his 
patient  to  submit  to.  These  are  essential  for  the  physician, 
whether  he  be  a  family  practitioner  or  a  hospital  consultant, 
for  to  him  will  assuredly  come  the  vast  majority  of  abdominal 
cases.  The  responsibility  is  laid  upon  him  of  making  accurate 
and  detailed  diagnosis.  There  is  really  little  difference  of 
opinion  as  to  what  treatment  ought  to  be  pursued  in  definite 
conditions ;  the  whole  difficulty  lies  in  a  weak  diagnosis. 
In  abdominal  disease  and  disorder  there  has  been  a  large  and 
new  demand  upon  the  physician's  skill,  and  there  seems  some- 
times to  be  a  tendency  or  a  desire  to  shirk  the  new  responsi- 
bility. This  is,  no  doubt,  due  to  the  idea  that  as  abdominal 
diagnosis  was  vague  in  the  past  it  must  remain  so  ;  and  the 
champions  of  "  exploratory  "  operation  do  little  directly  to 
remove  this  idea. 

It  seems  to  me  that  not  only  for  the  sake  of  the  physician's 
reputation,  but  also  for  the  maintenance  of  public  confidence 
in  surgery,  every  effort  ought  to  be  made  to  secure  increasing 
accuracy  in  abdominal  diagnosis — that  is,  in  the  differentia- 
tion of  conditions  which  present  a  certain  surface-resemblance 
to  one  another.  The  responsibility  for  such  advance  lies 
chiefly  with  the  hospital  physician,  for  it  is  he  who  has  the 


4       THE  STOMACH  AND  ABDOMEN 

material  from  which  this  can  be  made.  When  this  is 
done  "  exploratory "  operations  will  be  undertaken  on 
definite  and  enlightened  principles.  The  practitioner  and  the 
physician  will  then  realize  that  the  diagnosis  of  certain 
conditions  imperatively  demands  the  recommendation  of 
surgical  operation.  It  is  not  primarily  a  question  of  whether 
to  operate  or  not,  but  of  accuracy  and  completeness  of 
diagnosis.  "  Exploratory  "  operation  is  really  an  acknow- 
ledgment of  failure  ;  and  it  is  only  by  regarding  it  in  this 
light  that  advance  can  be  made. 


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CHAPTER   II 

EXAMINATION    OF  THE    ABDOMEN 

Some  introductory  statement  as  to  the  general  method  of 
examination  of  the  abdomen  seems  to  be  necessary,  but  it 
must  necessarily  be  elementary.  In  the  first  place  it  may  be 
stated  that  the  attention  of  the  practitioner  or  physician  is 
drawn  to  the  abdomen  by  the  presence  of  symptoms  referred 
to  this  part  of  the  body.  The  symptoms  vary,  however,  so 
greatly  in  different  cases,  and  according  to  the  organ  affected, 
that  they  cannot  be  referred  to  in  detail  here,  but  will  be 
dealt  with  when  each  organ  is  considered  separately. 

Physical  Examination. — ^The  physical  examination  of  the 
abdomen  as  a  whole  is  carried  out  by  means  of  inspection, 
palpation,  and  percussion. 

Inspection. — On  inspection  the  following  points  are  to 
be  noted:  {a)  the  degree  of  fulness,  or  prominence,  or  of 
localized  protrusion ;  {b)  the  movement  of  the  abdominal  wall, 
or  the  absence  of  such  movement,  during  respiration.  When 
fulness  or  distension  is  present  the  direction  of  bulging, 
whether  anterior  or  lateral,  is  noted.  In  persons  with  thin 
abdominal  walls  the  peristaltic  movements  of  the  stomach 
or  intestine  may  be  visible,  and  the  site  and  direction  of  such 
movements  ought  to  be  noted.  Such  movements  produced 
by  the  stomach  are  frequently  visible  ;  but  the  movements 
of  other  parts  of  the  intestinal  tract  may  also  be  seen.  These 
movements  can  be  stimulated  by  friction,  by  pinching,  or  by 
tapping  the  skin. 

The  epigastric  and  abdominal  reflexes  may  be  taken  at 
this  stage. 

Palpation. — In  palpating  the  abdomen  the  first  point  to 


6  THE   STOMACH  AND  ABDOMEN 

bear  in  mind  is  that  there  may  be  tenderness,  either  localized 
or  diffused.  It  is  necessary  therefore  to  begin  palpation  by 
lightly  passing  the  hand  over  the  abdomen  to  determine 
whether  such  tenderness  is  present  or  not.  In  some  cases 
there  is  marked  general  tenderness,  giving  rise  to  pain,  no 
matter  how  lightly  the  skin  is  touched.  In  such  cases  it 
will  be  found  that  by  passing  the  hand  quickly  but  gently 
over  the  surface  the  tenderness  rapidly  diminishes,  and  then 
by  pinching  the  skin  at  different  points  it  can  be  determined 
that  the  hypersensitiveness  is  a  surface  hyperaesthesia. 

The  measure  of  fatness  of  the  abdominal  wall  can  be 
determined  by  grasping  the  wall  between  the  thumb  and 
fingers,  and  it  has  to  be  remembered  that  the  thickness  of 
fat  in  this  position  may  be  from  three  to  four  or  more  inches. 
When  this  is  the  condition  of  the  abdominal  wall  the  palpation 
of  the  viscera  is  attended  with  great  difficulty  and  is  some- 
times impossible.  When  the  abdominal  wall  is  not  loaded 
with  fat  many  points  can  be  determined,  and  it  is  desirable 
that  a  routine  system  of  examination  should  be  followed. 
When  pain  is  referred  to  any  part  of  the  abdomen,  palpation 
is  usually  begun  there,  but  should  never  be  confined  to  the 
region  to  which  the  pain  is  referred.  My  usual  procedure 
is  to  begin  in  the  right  iliac  region  over  the  caecum  :  in 
palpating  here,  as  well  as  in  the  general  palpation  of  the 
abdomen,  it  is  necessary  to  learn  to  palpate  with  the  whole 
hand  flat  on  the  abdomen,  using  the  whole  length  of  the 
fingers  as  well  as  the  palm  of  the  hand  in  feeling  for  under- 
lying structures.  Rough  and  deep  pressing  with  the  points 
of  the  fingers  is  to  be  carefully  avoided.  The  reason  for  this 
is  that  the  structures  to  be  palpated  have  not  the  consistence 
of  solid  viscera.  In  the  right  iliac  region  the  caecum  can 
usually  be  felt  and  its  size  and  fulness  can  be  determined. 
By  moving  the  hand  upwards  the  ascending  colon  may  also 
be  felt,  especially  if  it  contains  faeces.  The  transverse  colon 
can,  under  similar  conditions,  be  also  frequently  felt,  and  the 
condition  of  the  descending  colon  and  pelvic  colon  may  also 
be  determined.  If  tenderness  be  present  at  any  point  or 
points,   such  points  of  tenderness  are  to  be  noted.     The 


EXAMINATION   OF  THE   ABDOMEN  7 

central  part  of  the  abdomen  is  occupied  by  the  small  intestine, 
and  its  coils  cannot,  as  a  rule,  be  felt. 

The  upper  half  of  the  abdomen  requires  careful  examina- 
tion, when  the  question  of  gastric  or  hepatic  disorder  has 
to  be  considered  :  this  includes  the  determination  of  the 
position,  size,  and  condition  of  the  stomach,  and  the  presence 
or  absence  of  local  swelling  or  local  tenderness  of  the  body 
of  that  viscus,  of  the  pylorus,  the  duodenum,  and  the  head 
and  body  of  the  pancreas.  The  edge  of  the  liver  has  also  to 
be  investigated,  to  determine  its  position,  its  character,  and 
at  the  same  time  the  character  of  the  anterior  surface  of  the 
liver  when  the  organ  is  enlarged.  The  gall-bladder  is 
investigated  at  the  same  time.  In  the  left  upper  segment 
of  the  abdomen  it  is  to  be  noted  whether  or  no  the  spleen' 
can  be  felt  projecting  beyond  the  ribs.  After  these  measures 
have  been  taken,  both  loins  ought  to  be  palpated  bi-manuallv, 
with  a  view  to  determining  the  condition  of  the  kidnej^  in 
each  loin,  and  in  some  cases  to  investigate  the  condition  of 
the  hepatic  and  splenic  flexures  of  the  colon. 

The  hypogastrium  is  also  to  be  palpated  with  a  view 
to  ascertaining  whether  there  is  distension  of  the  bladder,  or 
enlargement  of  any  other  pelvic  organ. 

Percussion. — Percussion  ought  to  be  carried  out  methodi- 
cally, from  above  downwards,  and  then  transversely  at 
the  level  of  the  umbilicus,  and  elsewhere  as  circumstances 
may  suggest.  The  points  to  bear  in  mind  are  the  position 
of  such  solid  organs  as  the  liver  and  spleen  and  the  fact  that 
over  the  intestine  the  percussion  sound  varies  as  the  bowel 
is  empty,  or  contains  faeces,  or  gas.  The  percussion  sound 
may  thus  vary  as  the  finger  is  moved  from  one  coil  to  another. 
When  fluid  is  present  in  the  abdominal  cavity  the  percussion 
sound  is,  of  course,  dull  when  percussion  is  made  over  the 
fluid,  and  the  note  is  altered  as  the  position  of  the  fluid  is 
altered  by  change  of  posture  on  the  part  of  the  patient. 

Having  made  these  introductory  remarks,  the  detailed 
examination  of  the  different  regions  of  the  abdomen  will 
be  dealt  with  as  the  organs  occupying  the  regions  are 
considered. 


Section  I.— THE  STOMACH 
CHAPTER   III 

TWO   CLASSES   OF   PRIMARY   DISORDER 

Introductory. — Disorder  of  gastric  digestion  giving  rise  to 
symptoms  of  less  or  more  discomfort  is  one  of  the 
commonest  ailments  to  which  men  and  women  are  subject. 
In  the  consideration  of  these  disturbances  in  the  past  clinical 
enhghtenment  was  hindered  by  ignorance  of  gastric  function, 
and  by  the  fact  that  surgical  interposition  was  not  even 
dreamed  of.  The  result  was  that  gastric  disorders  had 
crude  names  given  to  them — indigestion,  dyspepsia,  gastric 
catarrh,  gastritis ;  and  later  gastric  dilatation,  nervous 
dyspepsia,  gastralgia,  and  so  forth,  were  the  terms  used. 

Within  recent  years  knowledge  and  understanding  of 
gastric  digestion  has  been  put  on  a  sound  basis.  Concur- 
rently there  has  been  a  striking  advance  in  the  surgical  view 
of  what  the  abdomen  and  its  viscera  will  stand  at  the  hands 
of  the  expert  operator.  The  change  in  surgical  view  and  the 
rapid  application  of  a  new  faith  and  revelation  to  the  varied 
conditions  inside  the  abdomen  have  amazed  the  world,  and 
given  surgery  a  vast  field  for  beneficent  action.  But  it  is 
not  necessary  to  enlarge  upon  what  every  one  recognizes. 
It  is  referred  to  now  because  of  the  great  influence  the  appli- 
cation of  this  recently  acquired  faith  in  the  power  of  the 
peritoneum  and  of  abdominal  viscera  to  tolerate  surgical 
manipulative  skill,  so  long  as  it  was  aseptic,  has  had  on  the 
remarkable  advance  which  has  been  made  in  gastric  and 
abdominal  diagnosis.  The  fact  that  the  diagnosis  of  abdo- 
minal conditions  could  be  confirmed,  or  corrected,  on  the 
operating  table,  instead  of  only  on  the  post  mortem  table, 
did  much  to  stimulate  precision  in  observation  and  gave  it 


"    SIMPLIFICATION   OF  TEACHING  9 

a  living  interest  which  had  been  largely  wanting.  At  the 
outset  of  the  abdominal  epoch  in  surgery  diagnosis  was 
so  crude  that  the  abdomen  was  often  opened  with  the 
deliberate  object  of  making  a  diagnosis,  and  when  practicable 
of  dealing  with  the  condition  that  might  be  present.  The 
safety  with  which  the  mere  opening  of  the  abdomen  was 
attended  encouraged  and  gave  a  measure  of  sanction  to 
the  proceeding ;  but  it  necessarily  led  to  criticism,  even  if 
it  can  hardly  be  said  to  have  materially  hindered  progress. 
The  doctrine  that  the  abdomen  and  all  its  diseases  were  in 
future  to  be  a  region  wholly  in  the  hands  of  the  operating 
surgeon  began  to  be  promulgated  even  by  physicians  of 
repute.  This  doctrine  could  not  be  accepted  ;  for  internal 
diagnosis  in  the  abdomen  belonged  as  much  to  the  skiU  and 
art  of  the  physician,  and  to  the  practitioner-physician,  as 
it  did  in  the  thorax  and  the  head.  It  is  here  claimed  that 
it  is  the  duty  of  the  physician  to  make  accurate  abdominal 
diagnosis.  He  ought  to  know  which  organ  is  giving  rise  to 
symptoms  and  the  disorder  which  the  signs  and  symptoms 
indicate.  This  also  becomes  the  duty  of  the  practitioner,  for  he 
is  usually  the  first  to  see  sick  people  ;  and  he  is  not  prepared 
to  open,  or  to  advise  to  be  opened,  all  abdomens  which  are 
causing  discomfort  or  pain.  This  book  is  written  in  the  hope 
that  it  may  help  towards  the  realization  of  this  ideal  of  duty. 
The  indebtedness  we  owe  to  surgical  skill  and  technique  is 
fuUy  acknowledged,  and  will  be  referred  to  many  times  in 
these  pages. 

Simplification  of  Teaching. — The  stomach  is  the  organ  in 
the  abdomen  which  most  frequently  demands  the  attention 
of  the  physician  and  the  practitioner.  We  have  reached  a 
stage  when  the  teaching  of  gastric  disorder  and  disease  can 
be  put  in  line  with  recent  knowledge  ;  when  the  investiga- 
tions of  physiologists  can  be  applied  to  the  interpretation 
of  the  manifestations  of  disordered  function  ;  and  when 
advance  in  surgical  technique  calls  for  reasoned  accurate  and 
fuU  diagnosis.  The  accuracy  of  diagnosis  determines  the 
accuracy  of  prognosis  ;  and  the  experienced  surgeon,  so  far 
at  least  as  the  writer  knows  him,  no  longer  wants  to  open  an 


lo  THE   STOMACH 

abdomen  unless  he  sees  a  fair  prospect  of  benefiting  his 
patient  by  so  doing.  B}^  the  advances  which  have  been  made 
in  these  directions  the  writer  beheves  that  the  teaching  on 
the  stomach  and  on  the  whole  abdomen  can  be  greatly 
simplified.  Confining  attention,  in  the  meantime,  to  the 
stomach,  we  must  no  longer  lean  upon  such  a  term  as 
gastralgia,  upon  such  a  condition  as  dilatation,  upon  such 
words  as  "  indigestion  "  and  "  dyspepsia."  These  and  other 
words  were  good  enough  in  their  day  as  words  for  symptoms, 
but  they  have  no  longer  a  diagnostic  significance,  for  the 
question  now  asked  is,  Why  is  there  indigestion,  or  dj^spepsia, 
or  gastralgia,  or  even  dilatation  ? 

The  understanding  of  gastric  disorder  must  be  based, 
firstly,  on  knowledge  of  normal  function.  And  to  that  must 
be  added  the  recognition  that  all  stomachs  have  not  equal 
functioning  power  or  capacity.  The  practitioner  of  medicine 
deals  with  individuals  not  with  communities.  Knowledge  of 
the  average  capacity  of  the  community  does  not  help  him 
unless  he  recognizes  the  individuals  who  are  below  the 
average  or  above  it. 

The  normal  stomach  performs  two  functions.  It  has  a 
secretion  which  disintegrates  and  transforms,  that  is  digests, 
protein  foods.  Its  waves  of  muscular  contraction  mix  the 
food  with  the  digestive  secretions. 

The  secretions  are  the  catalj^tic  enzyme  pepsinogen  and 
hydrochloric  acid.  The  former  only  acts  if  the  latter  is 
present,  and  hydrochloric  acid  by  itself  is  of  no  use. 

It  has  been  shown  that  pepsinogen  is  not,  as  a  rule,  absent, 
while  it  resembles  other  catalytic  enzymes  in  being  operative 
in  small  quantity.  On  the  other  hand,  experience  has  shown 
there  are  great  variations  in  the  amount  of  hydrochloric 
acid  secreted.  Here  we  get  down  to  a  basal  fact,  and  we  have 
learnt  that  there  may  be  too  much  or  too  little  or  none  at  all. 
No  other  chemical  deviation  from  normal  occurs.  It 
becomes  therefore  a  sound  basis  for  the  classification  of 
disordered  function.  We  get  a  hyper  and  a  hypo  secretion. 
The  symptoms  ranged  round  these  are  indigestion,  dys- 
pepsia, gastralgia,  and  so  forth.     Diagnosis  and  successful 


TWO   CLASSES   OF   PRIMARY   DISORDER       ii 

treatment  are  determined  by  the  hyper  or  the  hypo  problem, 
not  by  words  of  Greek  or  Latin  derivation  coined  to  give  a 
semblance  of  dignity  to  a  feeling  of  discomfort  or  pain 
consequent  on  taking  food. 

When  we  turn  to  such  terms  as  atonic  dyspepsia  and 
dilatation,  we  have  terms  which  are  commonly  thought  of 
as  applicable  to  failure  on  the  part  of  the  contractile  mus- 
cular coat  of  the  stomach,  which  performs  the  mechanical 
or  mixing  work  of  the  viscus.  All  this  class  of  term  may  be 
used,  but  when  gastric  atonicity  and  dilatation  are  used  as 
diagnostic  terms  the  position  is  unfortunate,  Atonicity  and 
dilatation  really  depend  on  and  are  the  result  of  error  in 
or  deficiency  in  chemical  function  or  power. 

Two  Classes  of  Primary  Gastric  Disorder. — The  simple 
proposition  is  thus  reached  that  there  are  two  classes 
of  primary  gastric  disorder,  and  that  these  two  are  deter- 
mined by  the  amount  of  secretion  of  hydrochloric  acid. 
All  other  terms,  which  denote  symptoms,  become  grouped 
round  disorder  of  the  chemical  function  of  the  organ. 
Believing  that  this  is  the  basal  fact  upon  which  sound  under- 
standing of  gastric  disorder  must  rest,  and  the  only  founda- 
tion on  which  our  recent  knowledge  can  be  securely  arranged, 
the  writer  of  these  pages  has  long  adopted  and  taught  the 
method  of  investigation  which  such  a  belief  requires.  It 
is  on  this  principle  that  the  following  pages  are  offered  as  a 
contribution  towards  the  simplification  of  gastric  distur- 
bances and  the  provision  of  a  more  scientific  classification 
than  the  text-books  have  hitherto  entertained. 

We  begin,  therefore,  with  the  consideration  of  disorders 
of  function  and  deal  with  these  under  the  two  heads  of 
under-secretion  and  over-secretion.  With  these  established 
as  clinical  entities,  it  will  be  seen  how  they  give  rise  to  other 
conditions,  which  are  not  in  themselves  entities,  but  have 
been  produced  by  primary  disorder  of  chemical  function, 
and  are  in  reality  only  symptoms,  indicating  the  measure 
of  severity,  or  the  duration  of  disordered  function. 


CHAPTER   IV 

DISORDERS  OF  CHEMICAL  FUNCTION  ;   THAT  IS  OF  DIGESTION  : 
HYPOCHLORHYDRIA 

Introductory :  The  Relation  of  the  Stomach  to  Carbohydrate 
and  Protein  Food. — ^The  stomach  performs  two  important 
processes  in  the  extended  role  of  digestion.  The  principal 
of  these  two  is  chemical,  the  other  is  mechanical.  The  latter 
keeps  the  contents  of  the  viscus  moving  and  ensures  their 
thorough  mixing  with  the  chemical  substances  present  in 
the  glandular  secretions  ;  the  one  thus  becoming  the  mechani- 
cal complement  of  the  other. 

The  chemical  action  of  the  gastric  secretion  is  a  strictly 
limited  action.  It  deals  only  with  the  protein  elements  of 
the  food.  For  some  time  after  food  is  swallowed  the  ptyalin 
of  the  saliva  continues  to  act  upon  the  carbohydrate  of  the 
food,  the  act  persisting  until  the  gastric  contents  attain 
a  certain  measure  of  acidity.  This,  however,  appears  not 
to  be  an  essential  part  of  gastric  function,  the  stomach 
merely  serving  as  a  receptacle,  while  the  necessary  heat  is 
supplied  as  an  integral  factor  of  the  living  state.  Disordered 
gastric  function,  as  will  be  presently  seen,  may  interfere 
with,  and  speedily  arrest,  ptyalin  action ;  but  the  stomach 
secretion  itself  contributes  nothing  to  the  furtherance  of 
direct  carbohydrate  digestion,  although  it  materially  aids  in 
the  disintegration  of  the  carbohydrate  food  as  it  is  received 
into  the  stomach.  It  is  of  great  importance  to  bear  this 
fact  in  mind,  for  it  explains  various  of  the  phenomena 
present  in  indigestion. 

The  motor  function  of  the  stomach  plays  an  important 
part  in  the  trituration  and  churning  of  the  soft  carbohydrate 
food  ;    but  even  this  mechanical  action  has  only  a  Umited 


DISORDERS   OF   CHEMICAL  FUNCTION       13 

effect  upon  such  substances  as  lumps  of  potato,  grains  of 
imperfectly  cooked  rice,  the  glutinous  lumps  of  inefficiently 
prepared  sago  or  tapioca,  and  such  like.  It  follows  that 
these  substances,  when  introduced  into  the  stomach  in  the 
condition  indicated,  remain  in  the  stomach  practically 
unaltered,  and  are  often  the  direct  cause  of  disorder  and 
discomfort.  Their  hurtful  action  is  evidently  a  mechanical 
one,  for  all  observations  go  to  show  that  lumps  or  masses  of 
food,  of  even  relatively  small  size,  not  only  do  not  pass 
readily  through  the  pyloric  outlet,  but  by  stimulating 
the  pyloric  sphincter  they  lead  to  pyloric  spasm,  which 
prevents,  for  the  time,  the  passage  of  even  the  finely  disinte- 
grated and  the  partially  digested  portion  of  the  stomach 
contents  into  the  duodenum.  This  is  perhaps  the  most 
important  reason  for  insistence  on  the  need  of  thorough 
mastication,  and  explains  the  value  of  providing  finely 
divided,  indeed  minced,  food,  for  many  persons,  who  are  often 
erroneously  regarded  as  suffering  from  primary  gastric 
disturbance.  The  pyloric  sphincter  is  placed  where  it  is  to 
prevent  insufficiently  disintegrated  food  from  passing  into 
the  intestine,  and  in  this  respect  its  action  may  be 
accepted  as  necessary  and  beneficent.  But  while  that 
general  proposition  is  true,  it  is  necessary,  in  the  considera- 
tion of  individuals,  to  bear  in  mind  that,  like  all  other 
sphincters,  the  pyloric  sphincter  varies  greatly  in  its  sensi- 
tiveness, quite  irrespective  of  coarse  local  lesion,  or  demon- 
strable local  disturbance.  It  is  one  of  the  reflexes  which  in 
some  persons  is  readily  called  into  action  and  readily  becomes 
exaggerated.  Rough  illustrations  of  this  difference  in 
sensitiveness  are  available  from  the  feeding  habits  of  indi- 
viduals, and  of  the  effect  upon  them  of  common  articles  of 
diet.  Some  persons  swallow  great  lumps  of  potato  without 
conscious  suffering  as  a  result,  while  a  similar  proceeding  on 
the  part  of  other  persons  is  followed  by  discomfort,  pain, 
and  other  symptoms  of  severe  gastric  perturbation.  This  is 
also  true  of  many  other  carbohydrate  foods,  amongst  the 
more  common  of  which  are  barley  and  rice.  These  cereals, 
excellent  and  valuable  as  they  are  as  foods,  are  often  so 


14      ^  THE  STOMACH 

imperfectly  cooked  that  they  can  be  removed  from  the 
stomach,  unsoftened  and  unaltered,  hours  after  they  have 
been  partaken  •  of.  This  is  more  commonly  met  with  in 
the  case  of  barley  than  in  the  case  of  rice  ;  and  it  is  often  the 
essential  cause  of  the  indigestion  so  commonly  complained 
of  as  following  a  meal  of  which  barley-broth  formed  a  part. 
The  function  of  the  stomach  both  as  regards  its  treat- 
ment of  carbohydrate  and  of  protein  foods  having  been  thus 
defined,  the  consideration  can  now  be  taken  up  of  the  two 
types  of  disorder  of  chemical  function  as  these  can  be 
determined  by  the  physician.  The  first  which  will  be 
considered  is  under-secretion  or  diminished  secretion  of  hydro- 
cliloric  acid,  known  also  as  h3^pochlorhydria,  or  even  as 
achylia  ;  while  the  second  is  known  as  over-secretion  or 
hyperchlorhydria,  or  as  gastric  succorrhoea.  It  will  be  seen, 
as  these  two  great  types  of  gastric  disorder  are  discussed, 
that  they  give  rise  to  secondary  conditions,  and  that  these 
secondary  conditions  have  hitherto  been  regarded  as  primary, 
with  the  result  that  stomach  disorder  has  been  largely  looked 
upon  from  the  standpoint  of  a  S3rmptom  such  as  "  gastric 
catarrh,"  with  its  furred  or  coated  tongue,  as  "  dilatation," 
as  "  biliousness,"  as  "  chronic  constipation,"  as  "  weak 
digestion."  It  is  here  insisted  upon  that  this  way  of  looking 
at  stomach  disorder  has  to  be  abandoned  ;  and  that  the 
problems  to  be  faced  are,  in  the  first  place,  the  over  activity 
or  under  activity  of  gastric  secretion ;  in  the  second  place, 
the  condition  in  which  the  carbohydrate  and  protein  foods 
enter  the  stomach  ;  and  in  the  third  place,  the  determination 
of  the  normal  digestive  capacity  of  the  individual  with 
whom  we  have  to  deal,  and  who  is  our  patient,  who  has  come 
to  us  for  relief  and  if  possible  for  cure. 

Hypochlorhydria 

Diminished  Secretion  oJ  Gastric  Juice. — A  diminished 
secretion  of  gastric  juice  may  be  the  result  of  a  niunber 
of  different  causes,  and  it  is  of  practical  importance  to 
determine  so  far  as  possible  which  cause  has  acted  in  the 


HYPOCHLORHYDRIA  15 

particular  case  under  consideration.  While  the  recognition 
of  the  determining  cause  occupies  this  position  the 
effect  on  gastric  function  is  expressed  in  diminished  or 
arrested  secretion,  and  slow  and  uncomfortable  diges- 
tion. The  knowledge  of  this  alteration  in  secretion  not 
only  supplies  the  fact  necessary  for  an  intelligent  under- 
standing of  the  condition,  but  serves  as  the  only  reliable 
guide  in  determining  the  nature  of  the  remedial  measures 
to  be  taken.  A  diminution  in  the  amount  of  secretion  is 
often  found  associated  with  catarrhal  conditions  of  the 
mucous  membrane,  in  fact,  so  frequent  is  this  association, 
that  it  is  often  a  matter,  by  no  means  easy  to  determine, 
which  of  these  has  been  the  initial  factor.  The  place  of 
catarrh  as  the  causal  factor  will  be  considered  later.  At 
present  we  have  only  to  consider  the  condition  in  which 
diminished  secretion  is  the  primary  factor.  In  this  connec- 
tion it  is  necessary  to  postulate,  what  is  so  readily  regarded 
as  a  mere  platitude,  namely,  that  individuals  differ  greatly 
in  respect  of  gastric  function,  and  the  ease  or  efficiency  with 
which  gastric  digestion  is  performed.  This  embraces  the 
various  factors  included  in  the  process,  namely,  the  quantity 
of  secretion,  and  the  relative  proportions  of  pepsinogen 
and  of  hydrochloric  acid.  Of  pepsinogen  and  hydrochloric 
acid  the  latter  is  the  constituent  which  tends  to  be  the  more 
variable  in  amount ;  and  the  significance  of  this  fact  is 
realized  when  it  is  remembered  that  the  pepsinogen  ferment 
requires  hydrochloric  acid  to  activate  it,  that  is,  to  develop 
its  digestive  action.  Further,  a  relatively  small  amount  of 
pepsinogen  is  sufficient  for  the  conduct  of  gastric  digestion 
if  it  is  supplied  with  abundant  acid.  Many  observations 
support  this  position.  It  follows  as  a  consequence  that 
diminished  secretion  of  gastric  juice  is  rather  a  diminution 
in  acid  than  in  pepsin,  or  at  all  events  that  deficiency  in 
acid  is  relatively  greater  and  more  important  than  deficiency 
in  pepsinogen.  The  gastric  ferment  in  this  respect  corre- 
sponds with  other  ferments  or  enzymes  in  possessing  a 
stronger  action  than  might  be  expected  from  its  bulk,  if 
placed  in  surroundings  or  under  conditions  favourable  to 


i6  THE   STOMACH 

its  action.  Under  unsuitable  conditions  its  action  is  nullified 
no  matter  liow  large  its  quantity.  When  these  facts  are 
applied  to  the  individual  it  will  be  seen  that  the  practical 
aspect  of  diminished  gastric  secretion  resolves  itself  into  the 
question  of  the  quantity  of  acid  secreted. 

Individuals,  however,  differ  not  only  in  the  amount  of 
gastric  juice  they  secrete,  but  they  also  differ  in  the  sensi- 
tiveness of  the  secretion  to  conditions  which  are  apparently 
alike.  Or,  putting  it  differently,  there  are  individuals  whose 
gastric  secretion  is  so  limited  that  influences  which  may  not 
be  appreciable  to  the  average  person  readily  show  with  them. 
The  best  illustration  of  this  point  is  found  in  the  effect  of 
milk  in  such  individuals.  Pawlow  has  shown  in  his  wonder- 
ful experimental  work  on  digestion  in  dogs  that  milk  has  a 
powerful  inhibitory  action  upon  the  secretion  of  hydrochloric 
acid.  While  allowing  something  for  differences  between 
digestion  in  dogs  and  in  man  the  observations  on  the  former 
have  supplied  facts  which  may  with  full  assurance  of  their 
accuracy  be  used  for  the  explanation  of  some  digestive 
phenomena  in  man  which  are  by  no  means  uncommon. 
There  are  for  example,  a  considerable  number  of  persons 
who  are  conscious  of  stomach  discomfort,  with  a  sense  of 
fullness  or  of  having  a  lump  in  the  stomach,  after  taking 
milk.  The  explanation  of  the  feeling  of  discomfort  is  to 
be  found  in  the  inhibition  exerted  by  the  milk  on  the  gastric 
secretion,  particularly  in  the  hydrochloric  acid  secretion, 
and  this  to  such  a  degree  that  the  digestion  of  the  milk  is 
much  delayed,  although  not  necessarily  permanently 
arrested.  The  milk-curdling  ferment  is  present  in  sufficient 
quantity  to  ensure  the  coagulation  of  the  casein  ;  and  it 
is  this  coagulated  casein,  this  milk-curd,  and  its  undue 
retention  in  the  stomach  which  give  rise  to  the  discomfort 
referred  to.  The  disintegration  and  digestion  of  the  curd 
depends  upon  the  peptonizing  efficiency  of  the  gastric 
secretion,  and,  as  has  been  already  shown,  this  depends  upon 
the  secretion  of  the  gastric  acid.  We  are  thus  provided  with 
the  explanation  of  the  fact  known  to  every  physician  of 
experience,  that  with  some  persons  the  administration  of 


HYPOCHLORHYDRIA  17 

milk  becomes   almost   or   altogether   impracticable,    either 
because  of  the  difficulty  attending  its  digestion,  or  of  a  posi- 
tive dislike  to  it  on  the  part  of  the  patient,  due,  not  to  some 
stupid  prejudice,   as  is  not  uncommonly  thought,   but  to 
an  instinctive  repulsion,  almost  certainly  aroused  by  sen- 
sitiveness to,  or  exaggeration  of,  the  inhibitive  action  of  this 
particular  food.     Another  interesting  proof  of  the  inhibitory 
action  of  milk  upon  the  gastric  secretion  is  to  be  found  in 
the   effect,  readily  produced   in   some   persons,  of    taking 
milk,  usually  by  drinking  it,  along  with  flesh,  particularly, 
perhaps,  beef   and  mutton.      Many  individuals  have   dis- 
covered by  painful  experience  that  milk  and  flesh  taken  at 
the  same  meal  are  a  sure  cause  of  indigestion  to  them.     Such 
persons,  like  many  others,  who  have  clear  proof  in  their  own 
personal  experience  of  the  disastrous  results  of  transgressing 
certain  clear  laws,  often  seek  to  apply  their  law  universally, 
and  with  great  insistence.     Here,  as  in  other  departments  of 
popular  knowledge,  the  individual  experience,  especially  when 
self-acquired,  is  commonly  insisted  upon  as  the  universal  law, 
as  the  rule  apphcable  to  every  one,  and  obedience  to  which 
will  grant  freedom  from  suffering  to  all.     This,  alas  !  is  not 
the  case.     On  the  contrary,  many  persons  take  milk  and  meat 
together  with  impunity,  and  even  with  greater  comfort  than 
they  take  meat  alone.     The  explanation  of  the  difference  is  to 
be  found  in  the  individual  stomach  constitution,  in  the  chemi- 
cal personality  of  the  individual.     Herein,  indeed,  lies  at  least 
one  broad  line  separating  individuals  as  regards  their  digestive 
functions  ;  and  the  interpretation  of  the  difference  is  supplied 
by  Pawlow's  investigations.     One  side  of  the  line  holds  those 
whose  gastric  secretion  requires,  and  responds  sufficiently, 
but  not  over-much,  to  the  stimulation  of  flesh,  is  not  stimu- 
lated by  such  a  bland  fluid  as  milk,  but  is  inhibited  by  it. 
The  other  side  of  the  line  holds  those  whose  gastric  secretion 
is  readily  over-stimulated  by  flesh  and  by  aU  foods  which 
are  at  aU  savoury,  who  as  a  consequence  readily  secrete 
over-much  acid  ;  with  them  milk  seems  to  effect  the  restrain- 
ing  of   hydrochloric   acid   secretion,    while   the   degree   of 
restraint  is  only  sufficient  to  prevent  over-secretion. 

2 


i8  THE  STOMACH 

Thus  an  equal  balance  is  struck  in  such  persons  between 
the  food  taken  and  the  amount  of  secretion,  and  the  combina- 
tion, hurtful  to  others,  is  beneiicial  to  them. 

This  equilibrium  is  the  normal  standard  for  all,  and  its 
maintenance  implies  digestive  well-being,  so  far  as  the 
stomach  determines  well-being  ;  and  of  its  importance  in 
this  respect  there  is  no  doubt.  In  the  light  of  the  foregoing 
considerations  it  is  easy  to  acknowledge  the  existence, 
almost  the  necessary  existence,  of  great  individual  differ- 
ences. It  is  equally  easy  to  say  that  these  differences  depend 
upon,  and  are  the  expression  of,  chemico- vital  idiosyncrasies. 
The  determining  influences,  or  the  steps  of  the  chemico- 
vital  stimulation  which  result  in  over-secretion,  may  not,  with 
present  knowledge,  be  readily  followed  in  all  cases,  but  this 
side  of  the  subject  will  be  considered  later.  As  regards 
under-secretion  it  always  seems  more  easy  to  explain  it 
than  the  contrary  condition  by  simply  assuming  defective 
stimulus,  or  lethargic  functional  activity.  The  point  of 
practical  importance  is  the  recognition  of  the  facts  indi- 
cated, while  their  practical  significance  is  that  the  individual 
has  to  be  considered  individually  ;  it  has  at  least  to  be 
determined  into  which  of  two  great  groups  he  is  to  be 
placed,  and  whether  near  the  head  or  the  foot  of  the  group 
to  which  he  is  relegated. 

Causes  oJ  Diminished  Secretion  o!  Gastric  Juice. — The 
causes  of  diminished  secretion  of  gastric  juice  vary  greatly 
in  their  importance.  At  one  efid  stands  malignant  disease 
of  the  stomach ;  but  this  condition  does  not  fall  to  be 
more  than  mentioned  at  present.  At  the  other  end  stand 
the  cases  which  are  conveniently  regarded  as  functional  ; 
cases  in  which  deficiency  differs  in  amount  and  is  the 
expression  of  a  constitutional  state  which  can  be  brought  out 
by  dietetic  causes  such  as  have  been  already  described,  ^^'hen 
this  constitutional  defect  is  present,  it  sometimes  appears  as 
if  there  were  an  instinctive  attraction  to  savoury  foods,  and 
to  pungent  condiments,  because  of  their  stimulating  influence 
upon  gastric  secretion.  This  being  the  case  the  converse  is 
likewise  true,  namely,  that  partaking  of  the  more  bland  and 


HYPOCHLORHYDRIA  19 

imstimulating  foods  may  be  known  to  be  followed  by 
symptoms  of  indigestion.  Both  the  kind  of  food  and  the 
quantity  partaken  of  are  factors  of  primary  and  fundamental 
importance  when  dealing  with  persons  in  whom  this  idio- 
syncrasy is  pronounced.  The  next  factor,  the  influence  of 
which  is  great,  is  the  nervous  factor,  and  this  includes  all  the 
numerous  influences  which  act  through  the  nervous 
mechanism.  Even  the  failure  of  certain  foods  to  stimulate 
gastric  secretion  is  presumably  a  failure  to  initiate  nerve 
stimulation  of  sufficient  energy  to  lead  to  secretion  ;  but, 
putting  this  phase  aside,  there  are  other  common  nervous 
influences  which  have  a  definitely  inhibitory  action  upon 
secretion.  Various  emotional  disturbances  are  examples  of 
these.  Grief,  mental  depression,  anxiety,  may  all  have  this 
effect.  Physical  or  nervous  exhaustion  has  a  like  result,  so 
has  pain.  Gastric  catarrh,  as  has  been  already  stated,  is  a 
common  cause  of  diminution  in  secretion  no  matter  whether 
the  catarrh  be  acute  or  more  chronic  in  type,  while  the  cause 
of  the  catarrh  may  be  very  varied,  including  over-eating  as 
well  as  the  use  of  alcohol  in  excess.  Lastly,  there  is  the  great 
group  of  toxic  conditions  including  the  infective  fevers, 
embracing  amongst  others  pneumonia,  typhoid  fever, 
scarlatina,  measles,  malaria,  and  influenza.  In  all  these 
there  is  great  lowering  of  gastric  digestion  due  to  arrested 
or  diminished  secretion,  which  may,  no  doubt,  be  associated 
with  catarrh  ;  but  even  when  there  is  no  clear  indication  of 
catarrh,  the  lowering  or  even  arrest  of  gastric  digestion  is 
present  and  is  due  probably  to  the  definite  influence  of 
toxaemic  blood  upon  the  secretory  apparatus  of  the  viscus. 
If  this  common  condition  be  overlooked,  and  the  patient  is 
induced  to  partake  liberally  of  nourishment,  the  result  is  the 
speedy  production  of  a  gastric  catarrh,  which  may  seriously 
complicate  the  original  complaint,  and  embarrass  its  treatment. 
The  inability  of  the  stomach  to  digest  anything  approaching 
the  quantities  disposed  of  in  health  is  accompanied  with  loss 
of  appetite,  and  this  anorexia  is  in  itself  a  safeguard  to  the 
patient  if  ignorant  although  well-meaning  officiousness  does 
not  break  down  the  valuable  physiological  barrier. 


20  THE   STOMACH 

Clinical  Investigation  and  Symptoms 

Before  passing  to  a  consideration  of  the  symptoms 
emphasis  must  be  laid  on  the  importance  of  subjective 
phenomena — that  is  to  say,  the  patient's  history  of  his 
experiences.  This  history  is  of  first-rate  importance  in  all 
cases  of  stomach  disorder,  but  it  has  to  be  obtained  and 
sifted  with  great  care.  It  often  requires  tact,  judgment, 
and  skill  to  get  an  intelligible  story,  and  sometimes  the 
most  expert  skill  as  a  sympathetic  cross-examiner  will 
be  baulked.  In  the  great  majority  of  cases,  however,  one 
can  succeed  with  patience,  if  the  questions  are  put  with 
the  understanding  that  there  are  the  two  great  types  of 
digestive  disturbance. 

Symptoms. — The  symptoms  due  to  hypochlorhydria  vary 
within  considerable  limits,  as  might  be  anticipated,  in  view 
of  the  fact  that  they  result  from  delay  or  arrest  of  gastric 
digestion  and  the  retention  of  food  in  the  stomach.  The 
presence  of  food  which  has  not  effectively  stimulated  secre- 
tion soon  gives  rise  to  "  a  feeling  of  heaviness,"  or  of  a  "  load," 
referred  to  the  stomach.  This  discomfort  is  not  a  true  pain, 
although  to  begin  with  the  patient  may  so  describe  it.  Later 
there  is  a  feeling  of  distension  also  referred  to  the  stomach, 
and  due  evidently  to  accumulation  of  air  or  gas,  the  eructa- 
tion of  which  gives  temporary  relief.  If  any  other  part  of  the 
stomach  contents  is  eructated  there  is  usually  an  absence  of 
complaint  of  sourness  or  acidity  In  other  cases  the  symptom 
is  described  as  "  a  lump  "  or  "  ball "  referred  to  "  the  pit  of 
the  stomach  " — that  is,  to  the  epigastrium,  or  to  behind  the 
sternum.  The  feeling  of  heaviness  and  of  distension  or 
fullness  usually  comes  on  soon  after  food,  but  in  other  cases 
it  is  delayed ;  it  may  last  for  hours,  and  the  sense  of  discomfort 
and  oppression  may  only  get  relief  by  vomiting.  When  the 
condition  has  lasted  for  some  time  the  tongue  becomes  furred, 
the  appetite  impaired,  and  the  bowels  irregular  and  usually 
constipated.  There  may  be  vomiting  after  every  meal,  but 
only  in  severe  cases.  In  such  cases,  although  there  is  much 
general  discomfort,  want  of  vigour,  and  of  interest  in  all 


HYPOCHLORHYDRIA  21 

things,  there  is  not  the  same  degree  of  mental  and  physical 
inability  as  is  met  with  in  cases  of  hyperchlorhydria. 

Symptoms  Indefinite  or  Delayed. — In  some  x:ases  the  symp- 
toms, while  definitely  digestive,  are  very  indefinite.  In 
this  respect  they  may  be  in  striking  contrast  to  those  of 
hyperchlorhydria.  The  times  and  duration  of  discomfort 
are  not  only  indefinite,  but  the  patient's  statements  are 
frequently  so  interlarded  with  views  and  explanations  that 
the  utmost  patience  and  tact  on  the  part  of  the  physician 
may  fail  to  elicit  a  history  worthy  or  indeed  capable  of 
record ;  and  yet  the  very  indefiniteness,  and  the  entire 
absence  of  such  a  history  as  can  usually  be  obtained  from 
a  patient  suffering  from  hyperchlorhydria,  will  often  lead 
to  a  provisional  diagnosis  of  hypochlorhydria.  In  other 
instances  the  symptoms  are  delayed,  or  do  not  become 
intolerable  until  late  in  the  day,  and  may  continue  and 
even  become  more  severe  after  the  patient  has  gone  to  bed. 

The  following  cases,  taken  from  many,  illustrate  the 
foregoing  propositions. 

Case  1. — This  man  was  in  the  prime  of  life  and  looked 
well  nourished.  He  complained  of  weakness  in  the  legs  and 
inability  to  walk  any  considerable  distance,  half  a  mile 
tiring  him.  He  also  complained  of  discomfort  after  taking 
food,  and  that  recently  he  had  vomited. 

Symptoms  and  History. — On  questioning  him  it  was 
ascertained  that  the  gastric  symptoms  consisted  of  a  feeling 
of  the  food  he  took  lying  as  a  heavy  load  in  the  stomach  ;  this 
continued  all  day.  This  discomfort  led  him  to  consult  a 
medical  man  of  good  repute  living  near  where  he  was  spending 
a  holiday  on  account  of  his  health.  The  doctor  put  him  on 
"  light  diet."  Before  that  his  diet  had  consisted  of  porridge 
and  milk  followed  by  tea  for  breakfast ;  fish  for  mid-day 
dinner  three  days  a  week,  lentil  soup  and  semolina  the  other 
days  ;  a  plain  tea  at  night.  He  volunteered  the  information 
that  he  had  not  taken  butcher  meat  for  six  months.  A  week 
after  his  first  visit  to  the  doctor  he  vomited  about  8  p.m., 
having  only  taken  breakfast  and  dinner.  The  vomit 
consisted  of  the  bread  and  milk  he  had  taken  at  i  p.m.     A 


22  THE  STOMACH 

fortnight  later  he  vomited  four  times  one  day,  the  vomit 
consisting  of  the  food  he  had  taken.  At  this  point  he  was 
sent  to  see  me  at  the  infirmary.  There  was  no  history  of 
flatulence,  of  eructations,  or  of  constipation.  The  tongue 
was  fairly  clean  and  moist.  He  had  lost  28  lb.  in  weight 
during  the  preceding  six  months.  In  spite  of  this  loss  he 
was  still  a  big,  heavy  man,  rather  soft  looking,  but  not 
cachectic.  Examination  of  the  abdomen  gave  no  evidence 
of  gastric  dilatation  such  as  is  present  when  there  is  pyloric 
obstruction  from  any  cause.  The  stomach  was  indeed 
normal  in  size  and  position,  the  pylorus  was  not  palpable, 
and  nothing  abnormal  was  to  be  felt  in  any  part  of  the 
abdomen. 

The  leading  points  in  this  case  were  :  (i)  Food  lying  like 
"  a  load  "  in  the  stomach  ;  (2)  that  he  had  dieted  himself 
along  certain  popular  lines  without  benefit ;  (3)  that  he 
had  lost  2  st.  in  weight  in  six  months  ;  (4)  that  there  had 
been  vomiting  ;  and  (5)  the  absence  of  stomach  dilatation. 

The  provisional  diagnosis  was  (a)  simple  hypochlorhydria, 
or  {b)  malignant  disease  of  the  body  of  the  stomach.  The 
next  step  was  the  examination  of  the  stomach  contents. 
These  were  obtained  the  following  morning  after  a  test  meal 
and  showed  an  entire  absence  of  free  hydrochloric  acid. 
From  the  history  of  the  case  the  diagnosis  was  the  former  of 
the  two  alternatives.  The  patient  got  prompt  and  complete 
relief  from  his  troubles. 

Case  la. — Miss  M.,  aged  30,  was  sent  to  me  with  a  history 
of  headache,  constipation,  depression,  and  as  a  difficult 
neurotic.  She  herself  dwelt  much  upon  her  digestive 
discomforts,  and  her  strongly  expressed  opinion  was  that 
life  would  be  quite  pleasant  if  her  digestive  system  could  be 
put  right.  She  had,  as  is  common  in  digestive  inefficiency, 
beliefs  about  her  liver  being  sluggish  and  so  forth.  The 
symptoms,  as  dwelt  on  by  her,  pointed  to  stomach  discomfort 
with  heaviness  and  flatulence,  which  did  not  present  the 
relationsliip  to  meals  which  hyperclilorhydria  presents. 
The  fundus  of  the  stomach  was  enlarged.  The  next  step 
was  to  get  the  stomach  contents.     A  test  meal  was  given. 


HYPOCHLORHYDRIA  23 

and  showed  no  free  hydrochloric  acid.  On  a  second  occasion 
the  stomach  residuum  was  removed  shortly  before  luncheon  ; 
it  also  showed  entire  absence  of  free  acid. 

This  patient  had  been  dieted  on  the  lines  commonly 
adopted  whenever  digestive  trouble  is  complained  of,  but 
without  benefit.  She  was  now  treated  on  the  lines  indicated 
later,  and  the  bowels  were  regulated  by  means  of  a  simple 
laxative.  She  improved  rapidly,  and  lost  all  the  neurotic 
manifestations  which  had  been  so  pronounced.  Her  friends 
were  surprised  at  the  change  in  her  appearance.  In 
three  weeks  she  left  the  nursing  home  satisfied  as  to  the 
radical  change  in  her  condition.  She  continued  to  be  well 
when  last  heard  of. 

Case  2. —  M.  M.,  aged  23,  from  the  North  of  Scotland,  was 
admitted  to  my  ward  at  the  request  of  a  benevolent  lady  on 
whose  property  the  girl  lived.  She  had  been  an  invalid  for 
two  years,  and  had  been  kept  in  bed  most  of  the  time.  Her 
own  statement  was  that  she  had  an  "  ulcerated  stomach." 
The  stomach  trouble  had  begun  two  years  before,  with  pain 
or  discomfort  after  food  ;  later  she  began  to  vomit  food,  and 
she  stated  that  sometimes  there  was  blood  in  the  vomit. 
There  had  been  no  blood  for  two  months.  She  had  been 
treated  by  various  doctors,  and  she  had  been  in  a  local 
hospital  for  two  months,  without  apparent  benefit.  Her 
domestic  surroundings  -were  good  ;  she  helped  her  mother 
with  the  house  work,  and  she  used  to  walk  and  cycle  a  good 
deal.  She  was  intelligent,  animated,  fairly  well  nourished, 
and  not  anaemic.  The  height  was  5  ft.  2  in.,  and  the  weight 
8  St.  6  lb.  Appetite  was  good,  but  she  was  afraid  to  eat 
because  of  the  pain  which  followed.  She  lived  largely  on 
Benger's  food  and  Allenbury's  diet,  an  occasional  cup  of 
tea,  and  some  toast.  The  pain  was  referred  to  the  epi- 
gastrium ;  it  was  constant,  but  worse  half  an  hour  after 
taking  food.  Vomiting  usually  took  place  when  the  pain 
was  most  severe,  and  somewhat  relieved  it.  Lately  she 
had  vomited  more,  especially  if  she  deviated  from  her 
strict  dietar}^  The  vomit  came  up  easily,  and  was  not 
preceded  by  nausea.     She  suffered  from  constipation,  for 


24  THE   STOMACH 

which  she  took  compound  hquorice  powder  every  few 
da3^s. 

On  careful  inquiry  after  admission,  the  S3niiptoms  were 
not  definite  enough  to  warrant  a  diagnosis  of  gastric  ulcer. 
With  symptoms  of  this  kind  associated  with  constipation  the 
first  procedure  we  adopt  is  to  have  the  colon  thoroughly 
washed  out  by  means  of  a  douche  can.  She  was  given  light 
diet,  consisting  of  fish,  farinaceous  foods,  and  milk.  The 
stomach  discomforts  continued,  but  there  was  no  vomiting. 
Examination  of  the  abdomen  revealed  nothing  abnormal ; 
there  was  no  gastric  dilatation  or  ptosis,  and  not  a  suspicion 
of  tenderness  in  the  caecal  region. 

A  test  meal  was  then  given,  and  on  removal  showed  entire 
absence  of  free  HCl.  She  was  at  once  dieted  and  treated  as 
a  hypochlorhj^dric.  The  sudden  improvement  in  her  con- 
dition amazed  her,  and  in  a  few  days  her  discomforts  and 
pains  had  wholly  disappeared.  She  was  allowed  out  of  bed, 
and  rapidly  regained  the  health  and  vigour  she  had  enjoyed 
before  her  two  years  of  invalidism.  After  a  short  stay  in 
hospital  she  returned  home  and  has  continued  well. 

Case  3. — This  case  was  one  of  special  interest,  as  it 
occurred  in  a  soldier  during  the  war,  the  malady  keeping  him 
at  home  when  he  wished  to  be  at  the  front.  He  may  be 
designated  Captain  X.,  he  was  30  years  of  age,  and  had  been 
a  civilian.  The  story  he  gave  was  that  for  j^ears  he  had 
suffered  from  stomach  trouble,  and  had  to  be  very  careful 
of  his  feeding.  He  had  been  dieted  and  treated  by  several 
doctors  and  physicians  without  benefit.  The  main  symptom 
was  discomfort  and  pain  coming  on  about  10  p.m.  and  lasting 
until  2  a.m.  He  was  fairly  comfortable  in  the  forenoon  and 
the  afternoon.  There  was  no  nausea  or  vomiting,  but 
considerable  gaseous  eructation.  The  bowels  were  regular. 
He  mixed  up  his  symptoms  with  ideas  about  kinds  of  food, 
and  the  way  in  which  his  food  was  cooked.  WTien  he  tried 
to  live  on  army  rations  he  got  much  worse,  and  the  state  of 
his  digestion  was  such  that  he  was  not  allowed  to  go  overseas. 
He  was  kept  at  home  as  an  instructor.  He  thought  he 
suffered  less  when  living  in  his  own  house  and  with  his  own 


HYPOCHLORHYDRIA  25 

cook  to  prepare  his  food.  He  complained  bitterly  of  his 
condition  hindering  his  work  and  limiting  his  activities. 
His  bad  nights  made  his  day  duties  a  burden  which  he  often 
felt  to  be  more  than  he  could  bear,  and  yet  by  sheer  force  of 
will  he  kept  at  it. 

Examination. — He  was  poorly  nourished,  the  cheeks  were 
slightly  hollowed,  and  there  was  a  dusky  shadow  under  the 
eyes.  The  abdominal  wall  was  thin.  The  epigastric  and 
abdominal  reflexes  were  active.  No  peristalsis  was  visible. 
There  was  no  tenderness  on  palpation  in  any  region  of  the 
abdomen  ;  but  palpation  promptly  produced  loud  splashing 
over  the  stomach,  which  extended  to  the  level  of  the 
umbilicus  ;  its  fundal  end  was  enlarged,  but  the  right  border 
did  not  extend  beyond  the  middle  line.  This  was  the 
condition  three  hours  after  the  midday  meal,  which  had 
consisted  of  cold  chicken,  farinaceous  pudding  made  with 
milk,  and  a  tumblerful  of  milk.  By  means  of  the  stomach 
tube  some  ounces  of  stomach  contents  were  withdrawn,  which 
consisted  of  finely  divided  starch,  curd  of  milk,  and  pieces  of 
softened  chicken ;  it  showed  complete  absence  of  free 
hydrochloric  acid. 

Treatment. — ^The  diet  was  regulated  in  accordance  with 
this  finding,  and  a  prescription  was  given  containing  dilute 
hydrochloric  acid,  liquor  strychninae  hydrochlor.,  and  com- 
pound infusion  of  gentian.     This  visit  was  on  May  i6th. 

He  came  to  see  me  again  on  June  ist.  He  looked  much 
improved,  and  his  own  account  was  that  the  pain  had  dis- 
appeared, he  had  no  discomfort  after  food,  he  was  sleeping 
well,  and  was  more  energetic  and  lively.  The  weight  was 
9  St.  12  lb.  He  was  seen  two  hours  after  his  midday  meal 
and  the  stomach  splashed  on  palpation. 

On  June  6th  I  again  saw  him,  at  1.15  p.m.,  before  the 
midday  meal,  and  found  the  stomach  empty.  His  own  state- 
ment was  that  he  had  not  had  "  a  touch  of  pain  "  since  his 
first  visit  to  me,  and  that  he  was  sleeping  well.  On  June  27th 
I  saw  him  again.  His  weight  was  10  st.  4^  lb.,  he  was  quite 
free  of  gastric  or  other  discomfort,  and  was  full  of  gratitude 
for  increased  vigour,  and  comfort  in  his  work. 


26  THE  STOMACH 

The  history  in  this  case  pointed  to  hypochlorhydria,  but 
the  diagnosis  from  symptoms  alone  may  be  so  unsatisfactory 
that  it  is  unwise  to  be  guided  by  them,  especially  as  the  means 
of  attaining  certainty  are  within  easy  reach  when  the  stomach 
tube  can  be  used.  In  this  patient  I  used  the  stomach  tube 
at  our  first  interview,  and  a  correct  diagnosis  was  at  once 
established,  as  malignant  disease  of  the  body  of  the  viscus 
was  not  a  reasonable  proposition.  The  diet  of  white  flesh, 
as  chicken  and  fish,  farinaceous  puddings,  and  milk,  which 
had  been  prescribed  and  conscientiously  adhered  to,  under 
the  manipulative  skill  of  an  expert  cook,  was  departed  from. 
The  whole  idea  of  bland  and  soothing  nourishment  was 
revolutionized ;  milk  was  stopped,  farinaceous  puddings 
were  to  be  taken  with  stewed  fruit,  all  kinds  of  flesh  were 
allowed,  but  they  were  to  be  minced  and  eaten  with  stimulating 
condiments  and  sauces.  Acid  and  strychnine  were  also  given 
to  help  and  to  encourage  gastric  secretion.  By  these 
measures  stomach  function  and  secretion  were  stimulated, 
and  the  result  was  complete  removal  of  the  symptoms  which 
were  making  work  a  burden  and  life  a  struggle. 

The  next  case  illustrates  a  combination  of  hypochlor- 
hydria  and  air  swallowing  persisting  after  removal  of  the 
appendix. 

Case  4. — Mr.  W.  C,  aged  34,  a  mercantile  marine  officer, 
had  been  at  sea  for  fourteen  years,  and  consulted  me  on 
September  6th.  His  complaints  were  obstinate  constipation, 
the  bowels  never  moving  without  a  purgative,  and  frequent, 
almost  daily,  vomiting.  The  vomiting  had  become  more 
frequent,  and  sometimes  occurred  two  or  three  times  a  day. 
His  appendix  had  been  removed  in  Bombay  eighteen  months 
before  I  saw  him,  but  without  any  relief  to  his  symptoms. 

On  questioning  him  it  was  ascertained  that  he  had  a  feeling 
of  weight  and  heaviness  half  an  hour  after  food — "  a  feeling 
like  lead  "  in  the  lower  half  of  the  abdomen.  There  was  no 
pain.  He  often  felt  sick  before  breakfast,  and  if  he  did  he 
might  vomit  a  quarter  of  an  hour  to  half  an  liour  after  break- 
fast. The  vomiting  occurred  especially  if  he  took  anything 
hot,  cold  not  being  so  bad  in  this  respect.     He  might  vomit 


HYPOCHLORHYDRIA  ,^,;[  ^^ 

again  after  the  midday  meal.  He  never  vomited  after  4  p.m. 
The  vomiting  was  preceded  by  some  degree  of  nausea,  but 
it  did  not  appear  to  be  great.  The  motions  were  dry  and 
lumpy. 

Examination. — He  was  rather  pale  and  flabby  looking, 
but  stout.  He  had  never  had  malaria  or  other  fever  in  the 
East.  The  scar  of  the  appendix  operation  was  good.  The 
fundus  of  the  stomach  was  enlarged.  The  descending  and 
pelvic  colon  were  felt  small  and  contracted.  The  urine 
contained  neither  sugar  nor  albumin.  The  brachial  systolic 
pressure  was  135  mm.  Hg.  The  apex  of  the  heart  was 
slightly  to  the  left  of  its  normal  position.  From  the  fore- 
going facts  it  looked  as  if  it  were  only  necessary  to  find  a 
suitable  laxative  to  secure  the  removal  of  the  symptoms. 
With  this  object  in  view  I  prescribed  a  pill  containing  2 
grains  each  of  extract  of  cascara  and  extract  of  taraxacum 
with  I  grain  of  extract  of  belladonna,  to  be  taken  at  night. 

He  returned  to  me  on  September  26th,  when  he  informed 
me  that  half  a  pill  gave  him  a  free  motion  every  day,  but 
that  there  was  no  improvement  in  other  symptoms  ;  that 
he  vomited  daily,  sometimes  two  or  three  times  ;  and  had 
much  flatulence  after  taking  food,  feeling  "  blown  up  "  with 
it,  and  that  he  got  relief  when  he  got  it  up.  From  the  account 
he  gave  it  seemed  clear  that  he  was  an  air-swallower.  He 
was  examined  by  X-rays  and  watched  by  the  screen.  The 
screen  picture  was  not  satisfactory,  but  the  fact  of  air- 
swallowing  was  estabhshed  by  his  sense  of  distension  after 
the  bismuth  was  swallowed,  and  by  the  visible  and  marked 
projection  of  the  stomach,  the  projection  disappearing  after 
he  belched  up  wind.  I  asked  him  to  return  to  see  me  the 
following  day,  September  27th,  and  to  bring  his  vomit  for 
examination.  On  September  28th  he  brought  me  another 
specimen.  On  both  occasions  the  vomit  consisted  mainly 
of  disintegrated  cereal  food,  some  milk  curd,  etc.  On  both 
occasions  it  contained  no  free  acid.  I  prescribed  dilute 
acid,  strychnine,  and  gentian  ;  stopped  milk  and  farinaceous 
puddings  ;  put  him  on  meat  and  fish,  to  be  eaten  with 
savoury  sauces,  and  stewed  fruits.     He  reported  himself  on 


28  THE  STOMACH 

October  2nd.  He  stated  that  the  first  dose  of  the  mixture 
I  had  prescribed  had  reheved  him,  that  he  had  no  more 
vomiting  or  nausea,  and  practically  no  flatulence.  He  felt 
quite  well,  and  stated  that  the  bowels  were  regulated  by  one- 
fourth  of  the  pill  I  had  ordered  for  him.  He  was  naturally 
much  gratified  at  the  complete  removal  of  symptoms,  which 
he  had  suffered  from  more  or  less  for  the  fourteen  years  he 
had  been  at  sea.  An  interesting  and  important  observation 
made  this  day  was  that  the  brachial  pressure,  instead  of  being 
135  mm.  was  only  115  mm.  Hg.  I  saw  him  again  on  October 
8th  and  was  assured  that  complete  relief  was  maintained. 

Remarks. — The  points  of  special  interest  in  this  case  were 
(i)  the  air-swallowing,  which  stopped  when  the  hypochlor- 
hydria  was  successfully  treated  ;  (2)  that  it  was  not  a  case 
of  "  appendicular  dyspepsia,"  which  presumably  was  the 
diagnosis  which  led  to  the  removal  of  the  appendix  ;  and 
(3)  the  fall  of  20  mm.  Hg  when  the  gastric  condition  was 
rectified. 

Complications  o£  Hypochlorhydria 

The  word  complication  is  used  here  to  mean  certain 
manifestations  which  result  from  the  under-secretion  of 
what  we  may  still  speak  of  as  gastric  juice.  It  is,  how- 
ever, to  be  always  borne  in  mind  that  when  under-secretion 
is  spoken  of  by  the  physician  he  may  mean  in  one  case  an 
absolute  reduction  and  in  another  case  a  secretion  insuffi- 
cient for  the  food  which  has  been  taken.  Questions  of 
absolute  amounts  or  of  average  amounts  do  not  really 
help  him.  To  him  the  question  is  why  has  his  patient  the 
symptoms  of  gastric  disorder,  or,  to  use  the  popular  word, 
of  indigestion  ?  Is  the  indigestion  the  result  of  a  diet  larger 
than  the  particular  stomach  is  ever  able  to  deal  with  ;  or  is 
there  merely  a  temporary  failure  of  secretion ;  or  is  there  a 
combination  of  both  factors  ?  Whichever  it  be  the  results 
upon  the  stomach  are  the  production  of  catarrh  with  the  early 
supervention  of  dilatation.  It  is  at  this  point  that  diagnosis 
is  made  of  "  gastric  catarrh,"  or  "gastric  dilatation,"  or  of 
a  combination  of   the  two   conditions,  when  as  a  matter 


HYPOCHLORHYDRTA  29 

of  fact  these  terms  merely  indicate  the  recognition  of  a 
consequence,  and  is  not  in  itself  the  primary  malady.  It  is 
this  way  of  looking  at  these  cases  which  has  to  be  changed. 
It  is  the  time-honoured  way,  no  doubt,  and  it  is  wonderfully 
persistent,  but,  in  view  of  our  increased  knowledge  of  the 
stomach  and  of  digestive  processes  it  is  time  these  terms  were 
regarded  as  word-relics  of  the  past,  with  the  same  value 
as  dropsy  and  jaundice  and  other  words  which  indicate  a 
symptom  or  a  sign  of  an  antecedent  malady. 

Treatment  0!  Catarrh  and  Dilatation  due  to  Hypoehlorhydria 

When  this  is  realized,  treatment  is  guided  by  the  general 
principles  which  underlie  all  intelligent  therapeutics.  Ca- 
tarrh is  the  result  of  local  irritation,  for  we  leave  out 
of  account  here  such  causes  as  the  general  toxaemia  of  fevers 
and  other  infective  maladies.  The  irritation  is  caused  by 
what  has  been  swallowed ;  it  may  be  alcohol  in  some 
form;  but  it  may  be  food,  or  what  at  least  is  within  the 
pale  of  dietetic  substances.  It  may  be  caused  by  the  bad 
cooking  of  the  food  taken  ;  by  the  physical  character  in 
which  the  food,  even  when  well  cooked,  is  passed  into  the 
stomach  ;  and  by  the  quantity  being  excessive  for  the 
individual.  The  undue  retention  of  undigested  or  partially 
digested  food  leads  to  catarrh,  and  individual  stomachs  are 
sensitive  to  this  form  of  irritation.  And  at  the  back  of  all 
these,  and  apart  from  them,  is  the  question  of  a  secretion 
which  may  be  temporarily,  but  may  be  always  insufficient, 
and  definitely  requiring  stimulation  and  help  for  the  due 
performance  of  a  reasonable  amount  of  digestive  duty.  The 
first  principle  in  treatment  is  to  remove  or  to  alter  dietetic 
conditions  which  are  associated  with  the  catarrh,  and  here 
elementary  facts  have  to  be  enforced.  The  food  has  to  be 
reduced  in  amount,  it  ought  to  be  finely  divided,  and,  as  we 
are  dealing  with  catarrh  the  result  of  hypoehlorhydria,  milk 
ought  to  be  excluded  from  the  dietary.  The  food  ought  to 
be  savoury  and  the  meals  may  be  followed  by  the  administra- 
tion of  a  mixture  containing  acid,  strychnine,  and  an  aromatic, 
the  acid  ingredient  of  which  may  require  to  be  increased  in 


30  THE  STOMACH 

amount.  If  the  catarrh  is  very  pronounced,  with  thickly 
furred  tongue,  treatment  may  be  begun  by  giving  compound 
tincture  of  rhubarb,  with  small  doses  of  the  bicarbonate  and 
saUcylate  of  soda,  half  an  hour  before  food,  and  it  may  be 
given  in  hot  water.  The  colon  ought  to  be  emptied,  and 
this  can  be  effected  by  lavage  if  necessary,  or  by  a  laxative, 
repeated  at  intervals  of  hours.  Personally,  I  rarely  use 
salines  for  this  purpose,  preferring  combinations  of  cascara 
or  phenol  phthalein  with  taraxacum ;  in  other  cases  liquid 
parafhn  is  given,  and  in  still  other  cases  small  doses  of  castor 
oil.  When  the  catarrh  has  subsided,  fuller  doses  of  acid  are 
required  with  food  and  the  diet  has  to  be  stimulating. 

Dilatation  is  considerable  but  not  usually  great,  and  it  is 
mainly  of  the  fundus.  It  is  the  result  of  atonicity  of  the 
muscular  coat  due  to  the  catarrh,  or  consequent  on  the  too 
prolonged  retention  of  gastric  contents.  Atonicity  and  dila- 
tation are  the  results  of  unduly  retained  contents  in  the 
stomach,  as  is  common  in  other  hollow  viscera.  The  condi- 
tion is  recovered  from  under  the  line  of  treatment  indicated  ; 
but  it  may  be  slowly  recovered  from,  and  tonic  treatment 
must  be  combined  with  meals  small  in  bulk  and  easily 
digested.  The  treatment  has  to  be  persevered  with  until  a 
satisfactory  result  has  been  attained. 

Treatment  o£  Diminished  Gastric  Secretion 

The  treatment  of  the  individual  case  hangs  upon  the 
accuracy  of  the  differential  diagnosis.  When  the  symptoms 
of  indigeston  are  due  to  such  a  constitutional  state  as  has  been 
described  all  that  may  be  necessary  for  the  relief  and  cure  of 
the  condition  may  be  a  reduction  in  the  quantity  of  food 
taken,  especially  of  the  more  purely  protein  foods.  Close  atten- 
tion ought  to  be  paid  to  the  condition  of  the  bowels,  especi- 
ally to  their  daily  complete  evacuation.  A  tonic  laxative  such 
as  cascara  may  be  used  in  small  doses  taken  at  each  meal  or  a 
single  larger  dose  may  be  given  at  night.  Most  cases  are 
benefited  by  a  course  of  acid  and  of  bitter  tonics  taken  before 
meals.  These  include  nux  vomica,  or  its  alkaloid  strychnine  ; 
the  various  dilute  acids  as  hydrochloric,  nitric,  and  sulphuric  ; 


HYPOCHLORHYDRIA  31 

the  vegetable  bitters  as  quassia  and  calumba,  or  the  more 
aromatic  bitters  as  gentian  and  cascarilla.  All  these  tend 
to  stimulate  gastric  secretion  and  to  favour  digestion  ;  but 
they  are  necessarily  more  efficacious  if  at  the  same  time  the 
diet  is  regulated.  As  regards  diet  general  principles  only 
can  be  laid  down.  The  more  purely  protein  food  ought  to 
be  finely  divided,  savoury  in  character,  and  small  in  amount. 
The  carbohydrate  foods  are  usually  well  borne,  if  moderate  in 
quantity  and  if  prepared  in  attractive  and  palatable  ways, 
and  slowly  and  carefully  eaten  so  as  to  be  well  mixed  with  the 
saliva.  Milk,  for  the  reason  already  stated,  has  to  be  used 
with  caution,  and  never  in  association  with  fish  or  other 
flesh.  Pepsin  preparations,  as  the  acid  glycerine  of  pepsin, 
given  after  meals  is  often  an  efficient  and  pleasant  mode  of 
administration.  Extreme  cases  are  occasionally  met  with 
where  large  quantities  of  acid  are  not  only  well  borne  but 
are  even  curative,  A  medical  friend  assures  me  that,  when 
he  is  seized  with  an  attack  of  indigestion  his  invariable 
remedy  is  large  doses  of  acid,  and  that  he  always  succeeds  in 
promptly  curing  the  attack  by  this  means.  My  own  experi- 
ence leads  me  to  believe  that  this  kind  of  case  is  not  common, 
but  more  will  be  said  on  this  point  when  considering  the  reverse 
condition,  namely,  hypersecretion. 

In  the  toxic  cases,  that  is  in  the  cases  where  the  gastric 
inability  is  but  an  accompaniment  of  a  general  systemic 
infection,  nourishment  has  to  be  given  in  small  quantities, 
at  regular  and  short  intervals  as  the  stomach  can  tolerate 
it.  The  form  in  which  nourishment  is  given  is  indeed  of 
great  importance  and  requires  care  and  judgment  in  its 
determination.  Milk  stands  at  the  head  of  the  list  as  a  model 
food  in  such  cases,  but  it  often  requires  to  be  peptonized. 
Skimmed  milk  can  be  tolerated  sometimes  when  unskimmed 
milk  disagrees.  Milk  curdled  with  rennet  is  sometimes  taken 
willingly  by  patients  who  dislike  or  become  tired  of  milk  in 
the  fluid  form.  Milk  may  also  be  mixed  with  barley  water, 
which  contains  a  small  amount  of  nutriment ;  or  with  soda, 
potash,  or  seltzer  water,  which  of  course  contain  no  nutri- 
ment.    The  addition  of  any  aerated  water  makes  milk  more 


32  THE   STOMACH 

acceptable  to  some  palates.  The  milk  itself  may  be  aerated 
by  means  of  a  sparklet  or  in  an  ordinary  gasogene,  and  be 
drawn  off  as  required.  Thin  gruel  made  from  oatmeal  is  a 
valuable  food  and  can  be  mixed  with  milk.  Thin  arrowroot 
may  also  be  given,  prepared  with  milk ;  both  it  and  oatmeal 
gruel  ought  to  be  well  boiled  and  entirely  free  of  lumps,  and 
their  digestion  may  be  facilitated  by  adding  liquor  pancreati- 
cus  after  they  are  cooked.  Beef-tea,  chicken-tea  and  meat 
essences  generally  may  also  be  given  for  their  stimulating 
effect ;  but  they  ought  to  be  concentrated  and  given  in 
small  quantity  ;  and  it  is  to  be  remembered  that  they  contain 
very  little,  and  sometimes  no  nourishment  whatsoever. 
Their  action  as  stimulators  of  digestive  processes  and  as 
providing  certain  extractive  materials  whereby  nutrition  is 
indirectly  aided,  gives  them  a  value  beyond  their  direct 
nutritive  value.  Meat  jellies  occupy  the  same  place.  Jellies 
can,  however,  have  their  nutritive  value  enhanced  by  pre- 
paring them  partly  with  milk  or  with  white  of  egg.  Egg 
can  also  be  used  mixed  with  gruel,  arrowroot,  or  milk,  but  in 
no  case  ought  egg  to  be  added  until  the  medium  to  which  it  is 
added  has  cooled  sufficiently  to  prevent  the  albumen  coagu- 
lating. \Vhen  the  digestive  powers  are  returning  both  the 
yolk  and  the  white  may  be  given,  either  whisked  or  mixed 
with  milk  and  cooked  to  form  a  custard  pudding. 


CHAPTER  V 

increased  secretion  of  gastric  juice 
Hypersecretion  or  Hyperchlorhydria 

Introductory ;  General  Considerations. — The  consideration  of 
increased  secretion  of  gastric  juice  might  theoretically  be 
taken  up  under  the  two  headings  of  increase  in  the  secretion 
of  pepsin,  or  of  its  immediate  precursor  pepsinogen,  and 
of  hydrochloric  acid.  Practically,  however,  an  increased 
secretion  of  pepsinogen  may  be  set  aside,  as  little  if 
anything  is  known  of  the  condition. 

Notwithstanding  this  it  may  be  assumed  that  the  amount 
varies  in  different  individuals,  being  greater  in  some  than  in 
others  ;  and  that  its  free  secretion  will  no  doubt  expedite 
digestion  if  its  activating  acid  be  also  freely  secreted.  On  the 
other  hand,  an  increased  secretion  of  hydrochloric  acid  is  of 
much  importance,  for  it  is  usually  if  not  always  associated 
with  marked  clinical  manifestations  requiring  the  attention 
of  the  physician.  It  has  been  established  that  the  gastric 
secretion  in  health  is  called  forth  in  proportion  to  the  amount 
of  protein  food  which  has  to  be  dealt  with  ;  and  however 
subtle  the  character  of  this  arrangement  may  be,  it  is  but 
part  of  that  wonderful  chain  of  co-operation  and  adaptability 
which  Pawlow  has  shown  to  be  linked  all  through  the  digestive 
system.  This  normal  state  may,  however,  be  disturbed  so 
as  to  lead  to  hypersecretion,  that  is  to  an  amount  of  secretion 
over  and  above  what  is  required  for  immediate  needs.  In 
these  circumstances  some  of  the  acid  remains  free,  that  is 
uncombined  or  unincorporated  with  the  food,  and  it  is  this 
free  acid  which  gives  rise  to  the  discomforts  which  shall 
presently  be  referred  to.    This  over-secretion,  that  is  secretion 

33  3 


34  THE  STOMACH 

over  and  above  the  amount  required  for  the  digestion  of  the 
protein  taken,  is  known  as  hyperchlorhydria.  The  per- 
centage of  free  hydrochloric  acid  is  of  comparatively  little 
importance  from  the  practical  side  of  clinical  medicine,  as 
will  presently  be  shown.  Not  only  does  secretion  over  and 
above  what  is  required  take  place,  but  secretion  may  be  con- 
tinuous, that  is  may  continue  when  there  is  no  food  in 
the  stomach  with  which  to  combine.  The  term  gastric 
succorrhcea  is  confined  to  this  condition. 

The  Causation  and  Pathology. — Gastric  hyperacidity,  as 
manifested  by  heartburn,  acid  eructations,  or  water-brash, 
has  been  long  known  as  a  common  form  of  gastric  derange- 
ment, without  definite  knowledge  being  possessed  regarding 
its  essential  nature.  At  a  later,  and  indeed  at  a  compara- 
tively recent  date,  the  disorder  came  to  be  looked  upon  as 
due  to  fermentation  of  the  stomach  contents.  This  explana- 
tion was  no  doubt  inevitable  at  a  time  when  the  profession 
was  learning  its  first  lessons  as  to  the  true  nature  of  fermenta- 
tive processes,  and  of  the  part  fermentation  took  in  the 
production  of  the  processes  and  manifestations  of  diseased 
or  disordered  action.  It  would  indeed  be  still  unwise  to 
regard  this  view  as  having  been  superseded  in  all  quarters  by 
more  accurate  knowledge.  Knowledge  has,  however,  been 
advancing  both  in  regard  to  the  physiology  and  the  disturb- 
ances of  digestion.  Part  of  this  advance  has  shown  that 
there  occurs  a  true  hypersecretion  of  the  normal  acid  secreted 
by  the  organ,  and  clinical  investigation  has  established  this 
as  a  morbid  condition  which  can  be  differentiated  and  treated 
as  such.  It  is  to  this  condition  the  appellation  hyperchlor- 
hydria or  hyperchylia  is  applied,  and  which  we  are  here 
considering. 

When  we  inquire  into  the  cause  of  the  hypersecretion  it 
is  found  that,  as  might  be  expected,  there  are  many  causes 
which  may  be  regarded  as  th-e  determining  agents  or  factors, 
any  one  of  which  may  be  the  particular  factor  in  the  individual 
case.  The  marvel  is  that  ordinarily  the  adjustment  is 
so  accurate  between  the  kind  of  food  taken  and  the  amount 
of  secretion  poured  out,  for  the  normal  state  appears  to  be 


HYPERCHLORHYDRIA  35 

very  finely  balanced.  The  causes  of  hypersecretion  may  be 
considered  as  follows.  There  is  first  a  predisposition,  which 
can  only  be  regarded  as  constitutional.  Free  glandular 
secretion,  under  moderate  stimulation,  is  a  character  of 
various  glands  in  different  individuals,  and  is  by  no  means 
confined  to  the  gastric  glands;  just  as,  we  have  seen,  a 
sluggish  or  meagre  secretion  may  be  present  in  other  persons. 
It  is  important  to  bear  this  in  mind,  for  it  explains  the  readi- 
ness with  which  some  persons  suffer  from  the  symptoms  of 
over-secretion  just  as  we  have  seen  that  other  persons  suffer 
from  the  opposite  condition.  The  immediately  determining 
causes  may  be  placed  in  two  great  groups,  namely,  (i)  direct 
stomach  stimulation,  and  (2)  nervous  influences,  other,  of 
course,  than  those  which  are  included  under  the  former  head. 
The  Constitutional  Factor :  An  Acid  Dyscrasia.  —  This 
aspect  of  the  subject  requires  further  consideration.  The 
existence  of  a  predisposition  to  an  over-secretion  of  acid 
seems  to  me  to  be  bej^ond  doubt  :  it  is  met  with  in  early 
adult  life,  even  in  a  severe  form,  and  may  require  prolonged 
and  persistent  treatment  for  its  subjection.  This  predis- 
position I  have  ventured  to  call  an  "  acid  dyscrasia,"  and 
the  term  has  the  merit  of  precisely  defining  the  foregoing 
contention.  When  the  acid  dyscrasia  exists  it  is  found  that  a 
variety  of  circumstances  determines  its  stomach  manifesta- 
tion. Nervous  and  mental  influences  will  precipitate  an 
attack  in  such  persons ;  such  influences  having  no  such 
effect  in  persons  who  are  not  the  possessors  of  this  special 
constitutional  characteristic.  The  relationship  between 
nervous  influences  and  gastric  disorder,  particularly  the 
form  due  to  over-secretion  of  acid,  gave  origin  to  the  belief 
in  a  "  nervous  dyspepsia."  This  form  still  holds  a  prominent 
place  in  books  devoted  to  stomach  and  digestive  disorders. 
The  term  precisely  defines  the  underlying  idea  in  the  minds 
of  the  authors  of  those  works,  which  is  that  the  condition 
is  a  nerve  condition,  an  abnonnal  sensitiveness  of  sensory 
nerve  fibres,  a  neuralgia,  in  fact.  It  is  indeed  often  caUed 
"  gastric  neuralgia  "  or  "  gastralgia."  We  shall  presently 
show  that  there  is  another  way  of  looking  at  this  condition. 


36  THE  STOMACH 

which  appears  to  be  more  correct,  and  the  acceptance  of 
which  leads  to  the  adoption  of  therapeutic  measures  which 
are  much  more  beneficial  to  our  patients  than  if  we  treat 
them  on  the  assumption  that  it  is  a  neurosis  we  are  dealing 
with.  Based  upon,  and  necessarily  following  upon,  the  theory 
of  the  nervous  origin  of  the  condition  is  the  belief  that  this 
form  of  dyspepsia  manifests  itself  only  in  neurotic  persons. 
A  further  interesting,  although  extremely  unfortunate, 
development  of  this  neurotic  view  has  been  that,  if  a  patient, 
who  is  beyond  doubt  neurotic,  complains  of  digestive 
discomfort  or  disorder  it  is  at  once  taken  as  a  confirmation 
of  the  neurotic  state,  and  that  no  special  attention  is  to  be 
paid  to  the  gastric  derangement.  The  position  comes  to 
this ;  if  you  have  a  dyspepsia,  which  is  thought  to  be 
gastralgia,  you  are  a  neurotic  ;  and  if  you  are  a  neurotic, 
your  dyspepsia  is  a  mere  gastralgia.  A  very  simple  argument, 
but  one  which  we  hold  to  be  seriously  inaccurate.  This 
matter  will  be  dealt  with  presently,  and  our  contentions 
regarding  the  true  nature  of  the  condition  will  be  developed 
as  the  whole  question  of  hypersecretion  is  considered  in 
detail.  With  regard  to  the  constitutional  state  which  we 
have  termed  "  acid  dyscrasia,"  it  will  frequently  be  found  in 
rheumatic  and  gouty  people.  It  is  not  always  possible  to 
determine  this  association,  but  it  is  sufficiently  often  present 
to  warrant  the  inference  that  these  conditions  are  different 
manifestations  of  a  constitutional  or  vito-chemical  pecularity. 

The  Determining  Causes  of  Hypersecretion  :'  Food 
AND  Beverages 

Food. — The  first  factors  which  fall  to  be  considered  as 
determining  hypersecretion  are  all  substances  which,  when 
taken  into  the  stomach,  directly  stimulate  secretion.  They 
include  stimulating,  and  highly  or  full-flavoured  foods, 
condiments,  and  alcohol.  The  stimulating  foods  include 
beef  and  mutton  so  cooked  as  to  bring  out  their  most 
attractive  and  strongest  flavours — in  fact,  flesh  of  all  animals,^ 
birds,  or  fishes  possessing  such  flavours,  or  artficially  flavoured 


HYPERCHLORHYDRIA  37 

or  seasoned  to  a  high  degree  in  the  cooking.  There  is  no  doubt 
that  foods  so  prepared  have  this  effect,  and  this  is  their  value 
to  persons  whose  peptic  glands  require  strong  stimulation. 
That  this  is  a  natural  or  congenital  necessity  is  very 
doubtful.  It  is  probably  to  be  regarded  as  an  artificial  and 
acquired  condition,  the  result  of  long  habit,  and  is  to  be 
viewed  as  a  vicious  or  undesirable  acquisition,  unless  the 
view  is  adopted  that  the  want  of  efficient  response  to  all, 
save  the  strongest  impressions,  is  a  desirable  evolutionary 
development.  Such  a  position  is  certainly  physiologically 
unsound,  and  is  practically  injurious.  We  are  meanwhile, 
however,  not  concerned  with  this  type  of  person  ;  but  with 
the  fact  that  certain  foods  and  condiments  lead,  in  most 
persons,  to  free  secretion,  and  that  this  may  imply  that  the 
secretion  of  acid  may  be  in  excess,  and  lead  to  discomfort 
some  hours  after  the  meal  has  been  taken.  There  is  another 
element  in  this  which  occupies  an  important  practical  place, 
namely,  the  ease  or  difficulty  which  the  gastric  secretion 
experiences  in  disintegrating  the  meat  which  has  been 
swallowed.  It  is  apparent,  as  soon  as  it  is  stated,  that  the 
smaller  the  pieces  of  meat  swallowed  the  more  readily  does 
the  gastric  juice  act  upon  them.  The  converse  is  equally 
true,  and  thus  it  follows  that,  if  the  meat  is  present  in  the 
stomach  in  large  pieces,  they  continue  to  stimulate  secretion 
beyond  the  amount  which  is  readily  utilized  and  the  acid, 
instead  of  getting  fixed,  remains  uncombined  or  free,  and 
accumulates  in  quantity  sufficient  to  cause  discomfort  or 
pain.  When  meat  is  finely  divided  the  tendency  to  this 
result  is  greatly  lessened,  and  hence  the  value  of  finely  minced 
meats  for  those  who  suffer  in  this  way.  It  will  be  found  that  a 
given  weight  of  flesh,  eaten,  say,  as  steak,  may  lead  to  intense 
discomfort  or  pain,  while  the  same  quantity  finely  minced 
will  have  no  such  effect.  It  may  be  argued  that  if  the  more 
solid  meat  be  carefully  masticated  there  will  be  no  bad  result 
from  eating  it ;  but  the  fact  is,  that  the  necessary  amount 
of  mastication  to  convert  it  into  a  degree  of  division 
approaching  to  artificial  mincing  is  practically  beyond  the 
limits  of  education  in  the  vast  majority  of  our  patients,  and 


38  THE  STOMACH 

it  is  as  well  frankly  to  recognize  and  accept  the  position. 
From  this  it  is  a  simple  step  to  understand  that  tough  meat 
is  more  difficult  to  digest  than  tender  meat — a  fact  of  common 
knowledge  to  all  who  are  liable  to  digestive  discomfort.  A 
further  illustration  is  provided  by  egg  albumen  :  raw  or 
lightly  cooked  egg  albumen  is  readily  acted  upon  by  the 
gastric  secretion,  and  if  it  be  finely  broken  up  by  whipping  it 
is  still  more  easily  acted  upon.  On  the  other  hand,  if  it  be  so 
cooked  as  to  make  the  white  of  the  egg  tough  it  will  be  found 
that  lumps  of  it  escape  mastication  and  are  so  swallowed. 
Such  lumps  of  tough  white  of  egg  may  be  found  in  the 
stomach  hours  after  having  been  eaten,  and  associated 
with  fluid  containing  much  free  hydrochloric  acid  of  high 
digestive  value  when  tested  by  ordinary  laboratory  methods 
on  coagulated  albumin. 

The  continued  secretion  of  gastric  juice  under  such 
influences  as  have  been  described  is  of  considerable  interest, 
as  well  as  of  great  practical  importance.  Physiological 
experiment  on  animals  shows  that  the  introduction  of  inert 
substances  into  the  stomach  does  not  promote  gastric 
secretion,  and  Pawlow's  experiments  on  dogs  bears  out  this 
view.  From  this  it  might  be  thought  that  the  presence 
of  pieces  of  hard  meat,  or  of  tough  white  of  egg,  would,  at 
a  given  stage  in  digestion,  be  treated  by  the  stomach  as 
inert  substances.  This,  however,  is  not  the  case.  What 
happens  is  this ;  the  undigested  lumps  are  not  allowed  to 
pass  out  by  the  pylorus  ;  when  they  touch  it  the  sphincter 
contracts  and  they  are  swept  back  in  the  revolving  mass  of 
stomach  contents.  So  long  as  they  are  undigested  the 
gastric  secretion  continues,  with  the  result  that  there  is  an 
excess  of  secretion  and  the  presence  of  free  or  uncombined 
hydrochloric  acid  becomes  manifest.  The  classical  observa- 
tions made  through  a  gastric  fistula  have  long  been  accepted 
as  proving  the  action  of  the  pyloric  sphincter  in  refusing  to 
allow  pieces  of  solid  or  semi-solid  material  to  pass  from  the 
stomach.  The  correctness  of  this  observation  is  fully 
confirmed  by  clinical  experience. 

Passing  from  the  food  materials  which  ought  to  be  digested 


HYPERCHLORHYDRIA  39 

in  the  stomach,  we  have  to  consider  in  the  next  place  those 
which  are  not  digested  there,  but  are  more  or  less  broken  up 
and  triturated  by  the  movements  of  the  gastric  contents 
as  determined  by  the  peristaltic  contractions  of  the  viscus. 
The  materials  referred  to  all  belong  to  the  carbohydrate  foods, 
especially,  and  indeed  exclusively,  to  starch-foods.     These 
include  bread  of  all  kinds  made  of  wheat,  potatoes,  rice, 
and  porridge  made  from  any  of  the   cereals.     These   are 
sufficient  to  illustrate  the  general  principle  which  can  be 
laid   down   for   guidance   and   practical   application.     The 
potato  may  be  taken  from  among  these  as  most  strikingly 
illustrating   our   contentions.     This   useful   article   of   food 
may  have  deteriorated  in  quality  within  the  last  half-century, 
but,  whether  it  has  or  not,  it  is  very  frequently  eaten  in  a 
very  unsuitable  condition.     Instead  of  being  dr}/,  floury  or 
mealy,  it  is  sodden  and  waxy  in  appearance  and  consistence. 
To  pulverize  it  in  the  month,  as  it  ought  to  be  before  it  is 
swallowed,  requires  a  use  of  the  teeth  that  few  of  our  patients 
have  acquired,  with  the  result  that  unmasticated  lumps  enter 
the  stomach.     Such  masses  are  not  soon  digested  even  by 
amylolytic  enzymes  in  the  most  favourable  conditions ;  in 
the  stomach  this  action  has  but  little  time  to  act.     The  gastric 
juice  has  but  a  slight  effect  upon  the  lumps,  but  their  move- 
ment leads  to  a  certain  amount  of  trituration  and  disintegra- 
tion. The  breaking  down  process  is,  however,  slow,  so  that  the 
lumps  are  often  present  in  the  stomach  without  being  much 
changed  for  hours,  the  pylorus  refusing  to  allow  them  to 
pass  on  ;  the  process  by  which  retention  is  determined  being 
the  same  as  was  seen  to  be  the  case  with  lumps  of  protein 
foods.     Their  presence  also  leads  to  continued  secretion,  with 
the  like  result  of  much  free  acid  being  present.     That  lumps 
of  potato  may  remain  in  the  stomach  for  hours  is  known  to 
every  one  who  has  had  opportunities  of  seeing  the  vomit 
of  persons  inside  or  outside  hospitals.     My  own  observations 
lead  me  to  believe  that  when  vomiting  does  not  indicate 
anything  more  than  a  dyspepsia  the  vomit  often  contains 
abundant  free  hydrochloric  acid.     The  same  is  found  to  be  the 
case  when  the  stomach  contents  are  removed  by  the  tube, 


40  THE   STOMACH 

although  then  there  is  difficulty  in  getting  the  masses  out,  as 
they  stick  in  and  obstruct  the  tube.  The  demonstration  of 
the  presence  of  potato  is  most  striking  when  vomiting  occurs. 
Another  food  which  I  have  seen  in  stomach  contents  removed 
some  hours  after  having  been  eaten  is  rice.  I  have  seen  whole 
and  half  grains  of  quite  unaltered  rice  in  the  contents 
removed  by  the  tube.  I  have  also  seen  tough  lumps  of 
tapioca.  Of,  perhaps,  still  greater  interest  is  an  observation 
I  have  repeatedly  made  regarding  oatmeal  which  has  been 
eaten  in  the  form  of  porridge.  It  is  necessary  to  state  here 
that  oatmeal,  which  is,  of  course,  prepared  by  grinding  oats, 
is  sold  of  three  grades,  the  grades  being  coarse,  medium,  and 
fine.  These  terms  indicate  the  size  of  the  grains,  that  is  the 
degree  of  fineness  of  grinding,  and  not  the  quality  of  the  meal. 
The  coarse-ground  meal  is  very  frequently  preferred  to  either 
the  medium  or  the  fine,  and  our  remarks  will  be  confined 
mainly  to  it.  This  coarse-ground  meal  requires  to  be  long 
cooked  to  soften  it  and  to  make  it  easily  disintegrated  in 
the  stomach.  This  amount  of  cooking  it  very  often  does 
not  get.  I  have  frequently  found  that  on  withdrawing  the 
stomach  contents  some  hours  after  a  meal  partly  consisting 
of  porridge,  nothing  of  the  meal  remained  but  the  coarse 
grains  of  the  oatmeal  in  a  very  acid  fluid  containing  much 
free  hydrochloric  acid.  Along  with  the  oatmeal  porridge, 
milk  and  egg  may  have  been  taken  for  the  breakfast  meal, 
and  yet  no  trace  of  milk  curd  will  be  present,  and  no  trace  of 
egg.  All  has  been  digested  and  passed  out  of  the  stomach, 
while  the  coarse  grains  of  the  oatmeal  remain  in  an  intensely 
acid  medium.  These  facts  have  only  one  possible  explanation, 
namely,  that  the  coarse  grains  of  the  oatmeal  act  on  the  pyloric 
sphincter  as  the  other  masses  which  have  been  already 
described.  It  thus  appears  to  me  to  be  established  that  solid 
and  semi-solid  masses,  even  of  comparatively  small  size,  do 
not  only  not  readily  escape  through  the  p3iorus,  but  that  in 
addition  to  this  they  continue  to  stimulate  secretion,  and  thus 
lead  to  an  accumulation  of  free  hydrochloric  acid,  with  aU 
its  attendant  discomfort.  This  is,  then,  the  fact  which  has  to 
be  given  practical  consideration  to  in  the  selection  of  the 


HYPERCHLORHYDRIA  41 

food  to  be  given  to  our  patients.  Above  all  the  condition 
in  which  the  food  is  to  be  eaten  demands  much  more  attention 
than  is  usually  given  to  it.  Flesh  in  one  form  may  lead  to  the 
most  painful  symptoms,  in  another  form  it  may  give  rise  to 
no  such  symptoms.  Starch-food  in  one  form  readily  passes 
the  pylorus  and  has  its  digestion  completed  in  the  duodenum 
and  intestine,  while  the  same  food  in  another  form  will  cause 
the  most  severe  dyspepsia. 

Alcohol. — The  effect  of  alcohol  upon  the  gastric  secretion 
is  of  such  wide  interest  that  it  has  to  be  specially  considered. 
There  is  a  consensus  of  opinion  that  alcohol  stimulates  gastric 
secretion,  and  this  fact  is  the  warrant  for  its  use  at  meal 
times,  at  least  by  a  certain  number  of  people.  Such  persons 
no  doubt  belong  to  the  class  who  have  a  more  or  less  sluggish 
secretion  ;  but  it  is  as  unscientific,  and  as  incorrect,  to  ignore 
the  existence  of  this  class  as  it  is  to  deny  the  existence  of  the 
other  class.  The  fact  that  alcohol  stimulates  the  gastric 
secretion  is  confirmed  by  what  can  often,  if  not  invariably 
be  found  to  be  its  effect  in  persons  subject  to  hyperchlor- 
hydria.  In  them  the  taking  of  alcohol  with  food,  either  as 
spirits  or  as  wine,  may  determine  an  attack  of  acid  dyspepsia 
after  a  meal.  In  the  same  person  taking  whisky  and  water 
at  night,  some  hours  after  dinner,  will  often  be  promptly 
followed  by  heartburn  and  acid  discomfort.  An  interesting 
practical  fact  in  this  connection  is  that  this  evil  effect  of  the 
alcohol  can  be  prevented  by  adding  an  alkali  to  it ;  the 
ordinary  soda-water  being  sometimes  sufficient  for  this 
purpose,  while  in  other  instances  the  soda-water  is  better 
for  being  fortified  by  the  addition  of  more  bi-carbonate  of 
soda.  The  explanation  of  this  effect  is  doubtless  to  be  found 
in  Pawlow's  observation  that  bi-carbonate  of  soda  restrains 
the  secretion  of  acid  :  the  soda  may  therefore  be  regarded 
as  counteracting  and  annulling  the  effect  the  alcohol  would 
have  had  without  its  addition. 

Tea  and  Coffee. — The  only  other  beverages  which  may 
be  considered  are  tea,  coffee,  and  meat  extracts  ;  a  knowledge 
of  their  influence  upon  the  condition  under  consideration 
being  necessary  on  account  of  their  extensive  use.     Tea  may 


42  THE  STOMACH 

be  taken  first  as  it  is  the  more  used.  The  effect  it  has  upon 
gastric  digestion  has  been  much  investigated  and  as  the 
result  of  these  investigations  there  is  no  doubt  that  it  has 
an  arresting  influence.  The  precise  degree  of  influence  it 
exercises  depends  upon  the  quantity  taken  and  the  strength 
of  the  infusion.  Taken  in  quantity  or  in  strong  infusion  it 
completely  arrests  gastric  digestion  by  its  direct  effect  upon 
the  digestive  ferment ;  in  smaller  quantity  it  reduces  the 
vigour  of  the  digestive  process,  and  correspondingly  lengthens 
the  process.  The  action  is,  according  to  Roberts,  due  to  the 
tannin  in  the  infusion,  the  theine  and  aromatic  substances 
present  having  a  negative  effect.  This  important  action  is 
not  without  its  beneficent  side  :  it  is  not  wholly  and  in- 
variably or  always  an  undesirable  or  hurtful  action.  This 
other  side  is  seen  in  the  influence  and  effect  it  exercises  in 
hypersecretion.  Clinical  observation  has  convinced  me  that 
the  wholesale  condemnation  of  tea  drinking  in  all  kinds  of 
dyspepsia  is  not  warranted  by  the  facts.  What  will  be 
found  is  that  in  h5^perchlorhydria,  when  the  characteristic 
symptoms  of  the  condition  begin  to  make  their  appearance 
some  time  after  a  meal,  the  taking  of  a  cup  of  tea  often  has  a 
very  marked  effect  in  relieving  the  symptoms,  and  preventing 
their  further  development.  A  cup  of  hot  water  does  not  have 
nearly  the  same  effect,  it  may  give  temporary  relief,  but  the 
relief  is  often  succeeded  by  an  exacerbation  of  the  symptoms. 
The  effect  of  tea  infusion  is  due  in  the  first  instance  to  the 
dilution  of  the  stomach  contents,  leading  to  a  corresponding 
dilution  or  weakening  of  the  acid  present,  acting  in  this 
respect  as  hot  water  acts  ;  but  its  further  effect  seems  to  be 
to  arrest  secretion.  This  seems  to  me  to  be  the  only  possible 
inference  from  what  is  undoubtedly  a  clinical  fact,  while  it 
bears  out  and  explains  the  recognized  injurious  effect  of  tea 
drinking  in  the  opposite  class  of  case.  This  in  fact  explains 
what  is  so  often  to  be  noted  in  popular  or  common  beliefs, 
namely,  that  they  have  both  a  true  and  a  false  side.  Tea  is 
hurtful  in  one  form  of  dyspepsia,  helpful  in  another,  so  that 
the  successful  regulation  of  this,  what  might  be  deemed  a 
very  simple  matter,  is  determined  by  the  correctness  of  the 


HYPERCHLORHYDRIA  43 

differential  diagnosis  of  the  type  of  dyspepsia  present  in  the 
individual  patient. 

Coffee  is  regarded  by  Roberts  and  others  as  hav'ing  the 
same  restraining  and  arresting  action  on  peptic  digestion 
that  tea  has.  It  probably  has  the  same  influence  as  tea  upon 
the  gastric  secretion,  but,  owing  to  the  much  more  limited  use 
of  coffee,  there  is  not  the  same  amount  of  clinical  observation 
available  regarding  it.  I  have  not  been  able  so  far  to  satisfy 
myself  regarding  the  effect  of  the  small  cup  of  cafe  noir  which 
is  sipped  so  commonly  after  dinner.  Taken  in  the  afternoon 
it  may  arrest  hypersecretion  as  effectively  as  tea.  The 
morning  cafe  au  lait  is  preferable  to  tea,  especially  if  that  meal 
is  largely  a  carbohydrate  meal. 

Meat  Extracts. — Passing  next  to  meat  extracts,  of  which 
beef,  mutton,  or  chicken-tea  or  soup  may  be  taken  as  samples, 
they  have  long  occupied  a  prominent  place  in  the  sick-room, 
and  in  the  dietary  of  the  invalid  and  convalescent.  They 
will  doubtless  continue  to  be  much  used  because  of  certain 
valuable  properties  they  possess,  although  they  may  be 
shorn  of  much  of  the  value  so  commonly  attributed  to  them. 
They  certainly  serve  as  admirable  and  valuable  stimulants 
in  some  conditions.  Turning  to  their  effect  on  gastric 
digestion,  Roberts  *  showed  that  they  delayed,  embarrassed, 
or  practically  arrested  it ;  the  measure  of  the  effect  being 
determined  by  the  proportion  or  percentage  of  beef-tea 
present  in  the  digesting  mixtiure.  If  this  effect  had  been 
definitely  proved  to  take  place  in  the  stomach,  or  if  this  could 
be  shown  to  be  the  whole  truth  about  its  action  in  the 
stomach,  it  would  be  difficult  to  regard  its  use  with  any  favour 
whatever.  As  to  the  correctness  of  the  result  when  experi- 
ment is  made  outside  the  body  and  in  a  flask  there  need  be 
no  question.  Practically  there  is  this  objection  to  the  method 
of  investigation,  namely,  that  beef -tea  is  not  given  to  patients 
when  a  considerable  protein  meal  is  in  the  process  of  digestion. 
From  the  side  of  clinical  observation  it  has  often  appeared  to 
me  that  beef-tea  not  infrequently  caused  s^miptoms  of 
indigestion  due  to  the  stimulating  of  gastric  secretion  while 

*  Sir  William  Roberts,  Digesticti  and  Diet.    London.  1S97. 


44  THE  STOMACH 

there  was  no  food  present  in  the  stomach  for  it  to  act  upon. 
This  chnical  conviction  is  abundantly  confirmed  by  Pawlow's 
work.  He  found  that  meat  extracts  had  a  decided  effect 
in  stimulating  gastric  secretion.  In  fact,  he  found  that  when 
the  psychic  stimulus  in  dogs  was  abolished  by  division  of  the 
vagus  he  could  effect  the  digestion  of  solid  food  introduced 
into  the  stomach  by  first  stimulating  secretion  by  introducing 
meat  broth.  If  this  was  not  done  the  solid  food  introduced 
began  to  decompose.*  In  short,  all  his  experiments  go  to 
show  that  meat  extract  is  perhaps  the  most  powerful  chemical 
stimulus  that  can  be  used  for  promoting  gastric  secretion. 
This  therefore  warrants  our  contention  that  meat  extracts 
frequently  lead  to  hyper-secretion,  and  that  their  use  is  to 
be  carefully  watched  if  they  are  to  be  used  at  all  in  persons 
suffering  from  or  subject  to  hyperchlorhydria. 

Symptoms  and  their  Interpretation 

In  approaching  the  consideration  of  the  symptoms,  a 
few  general  remarks  may  be  made  on  what  is  recognized 
as  acid  dyspepsia.  The  symptoms  which  characterize  that 
condition  are  burning  pain  at  the  cardiac  orifice  of  the 
stomach,  acid  eructations,  water-brash,  usually  flatulence, 
and  constipation.  The  idea  that  these  symptoms  were 
due  to  the  presence  of  other  acids — as  lactic  and  butyric — 
produced  by  fermentative  processes  in  the  stomach,  is 
presumably  no  longer  more  than  a  myth  in  medicine.  The 
acid  which  is  present,  and  present  in  abundance,  is  HCl, 
secreted  by  the  oxyntic  glands  of  the  stomach. 

Symptoms.! — As  has  been  stated  in  a  previous  chapter,  it 
requires  patience  and  method  to  obtain  an  accurate  record 
or  a  true  picture  of  the  symptoms  in  gastric  disorder.  The 
plan  I  have  developed  is  simple  and  practical,  and  gives 
satisfactory  results.  I  begin  by  inquiring  how  my  patient 
feels  on  getting  up  in  the  morning  ;  then  the  hour  at  which 
he  breakfasts,  and  of  what  that  meal  usually  consists ; 
how  he  feels  after  breakfast,  and  if  any  pain,  discomfort,  or 

*  T.oc.  cit.,  p.  1 02. 

I  Reprinted  from  British  Medical  Journal  of  April  i8th,  1903. 


HYPERCHLORHYDRIA  45 

other  symptom  is  experienced  during  the  forenoon,  and  the 
hour  at  which  these  come  on,  how  long  they  last,  and  whether 
they  continue  up  to  the  time  of  taking  the  midday  meal. 
If  symptoms  continue  up  to  the  midday  meal  I  ascertain 
the  effect  that  meal  has  upon  them — whether  they  are  at 
once  aggravated,  or  materially  relieved,  or  entirely  removed, 
at  least  for  the  time.  I  then  inquire  as  to  the  composition 
of  the  mid-day  meal.  This  is  followed  by  inquiries  as  to  the 
symptoms  during  the  afternoon  and  so  on  until  bedtime,  and 
later  if  necessary.  This  method  I  have  found  to  be  the  only 
way  to  obtain  exact  knowledge  of  sjonptoms,  and  the 
symptoms  so  obtained  are  of  the  greatest  value  in  helping 
to  determine  the  part  of  the  digestive  process  which  is  at 
fault.  Occasionally  an  observant  patient  gives  all  this 
without  detailed  questioning,  but  such  patients  are  rare  ; 
the  majority  give  a  description  which  is  usually  irrelevant 
and  confused,  symptoms,  times,  and  explanations  being 
intimately  interwoven  and  mixed. 

The  history  thus  obtained  is  often  so  characteristic  as  to 
warrant  the  diagnosis  of  hyperchlorhydria  without  the 
chemical  examination  of  the  gastric  contents.  The  facts 
brought  out  in  such  a  history  are  somewhat  as  follows  :  The 
patient  feels  quite  well  in  the  morning,  and  has  no  discom- 
fort until  during  the  forenoon  some  time.  He  can  often 
state  the  hour  at  which  discomfort  begins — one  to  two,  or 
two  and  a-half  hours  after  breakfast — the  time  varying  in 
different  cases,  and  even  in  the  same  case.  The  pain  after 
lasting  an  hour  or  two  may  pass  off,  to  reappear  an  hour 
or  longer  after  the  midday  meal.  If  the  pain  continue  right 
up  to  the  time  of  taking  the  midday  meal,  partaking  of  this 
meal  removes  it  for  a  time,  the  period  of  relief  varying  from 
half  an  hour  to  an  hour  or  longer.  The  duration  of  the 
interval  of  comfort  depends  upon  the  severity  of  the  condition 
and  the  composition  of  the  midday  meal.  This  sequence 
of  events — meals,  intervals  of  relief,  reciurrence  of  pain  or 
discomfort — may  be  maintained  throughout  the  rest  of  the 
day.  If  the  last  meal  of  the  day  be  taken  near  bedtime,  the 
patient  may  be  wakened  from  sleep  by  pain  and  other 


46  THE  STOMACH 

symptoms  which  may  keep  him  awake  for  an  hour  or  two. 
The  pain  or  discomfort  varies  within  wide  hmits  ;   it  may  be 
severe    and   acute,    and    described    as   grinding,    gnawing, 
boring,  burning  ;    or   the   sensation  may  be  of   dragging, 
of  weariness,    of   distension,    or   a  hunger-discomfort.     The 
pain  is  usually  referred  to  the  epigastrium,  but  it  may  go 
through  to  the  back  near  the  spine  ;    it  may  be  present 
behind  either  shoulder-blade,   or   be  most  marked   in  the 
normal  position  of  the  pylorus,  or  over  the  liver  behind. 
The  measure  and  the  site  of  the  pain  depend  upon  the 
duration  and  severity  of  the  condition  more  than  on  any 
neuropathic  tendency  in  the  individual.     There  is  indeed 
no  department  where  so  much  is  attributed  to  disordered  or 
disturbed   innervation,    as    in   gastric    disorders,    and   the 
exaggeration  of  this  factor  tends  to  relegate  to  a  subsidiary 
place  the  part  taken  by  diet  and  altered  secretion  in  the 
production  of  the  symptoms.     Symptoms  due  to  one  or 
other  or  both  of  these  are  referred  to  as  nervous,  as  if  a  nerve 
condition  were  the  primary  and  essential  factor,  when  it  is 
but  the  sensory  index  of  disordered  chemistry.     In  addition 
to  pain,  there  may  be  epigastric  tenderness,  but  this  is  only 
present  in  pronounced  cases  of  considerable  duration.     The 
tenderness  is  quite  superficial,  and  is  readily  overcome  by 
gently  rubbing  or  handling  the  skin,  and  then  deep  palpation 
can  be  practised  without  causing  pain.     Other  symptoms  re- 
ferred directly  to  the  stomach  are  flatulent  distension,  gaseous 
eructations,  heartburn,   acid  eructations  and  water-brash. 
The  eructation  of  gas  or  of  a  small  quantity  of  acrid  material 
gives  relief,  temporary  usually,  but  often  very  marked  and 
out    of    all   proportion,   one  would  think,   to  the  amount 
eructated.     The  bowels  are  constipated,  or,  even  if  there  be 
daily  action,  the  removal  of  the  intestinal  contents  is  incom- 
plete.    In  severe  cases  there  is  sometimes  great  physical 
and  mental  misery,  coming  on  or  attaining  their  worst  when 
other  S3niiptoms  are  at  their  height.     The  most  prominent 
of  these  is  a  sense  of  physical  and  mental  exhaustion,  langour, 
weariness,  and  weight  in  the  lower  limbs,  and  inability  to 
apply  mind  or  body  to  any  work.     Another  symptom  has 


HYPERCHLORHYDRIA 


47 


been  graphically  described  by  Sir  W.  Roberts  under  the 
designation  of  "  paroxysmal  pyrosis,"  and  he  regarded  it  as 
an  "  abortive  and  incomplete  act  of  vomiting."  While 
agreeing  with  him  that  this  special  symptom  only  occurs 
during  the  presence  of  surplus  acid  in  the  stomach,  I  think 
that,  instead  of  its  being  an  abortive  act  of  vomiting,  it  is  a 
pyloric  phenomenon. 

Emphasis  has  to  be  laid  on  the  fact  that  this  disorder 
of  secretion  is  attended  with  very  marked  nervous  phenomena. 
Some  of  these  have  been  mentioned,  and  they  must  be  borne 
in  mind  ;  but  in  some  instances  the  mental  depression  is 
very  great,  and  even  a  cause  of  anxiety,  whilst  in  others 
complete  incapacity  for  work  of  any  kind  is  experienced. 
The  severity  of  the  nervous  symptoms  are  not  determined 
by  class  differences,  the  manual  worker  may  be  more  sensi- 
tive than  the  brain  worker,  but  the  converse  is  equally  true. 
Some  persons,  irrespective  of  class,  tolerate  and  bear  pain 
and  discomfort  much  better  than  others,  while  other  persons 
are  hyper-responsive. 

The  Explanation  of  the  Symptoms. — To  understand  the 
symptoms  of  gastric  disorder  it  is  necessary  to  postulate 
precise  knowledge  and  a  clear  comprehension  of  digestive 
processes  in  the  stomach.  Our  food  consists  of  three  great 
classes  of  nutriment — starch,  protein,  fat.  The  main  sources 
of  starch  are  cereals,  including  rice,  and  potatoes  ;  of  protein 
are  meat,  milk,  eggs  ;  of  fat  are  butter,  milk,  meat.  The 
starches  are  prepared  for  food  by  baking  and  boiling, 
being  unfit  for  human  food  in  an  uncooked  state.  The  object 
of  cooking  is  to  break  the  starch  capsules  and  to  disintegrate 
the  starch  particles  so  as  to  expose  them  to  the  amylolytic 
enzyme  of  the  saliva  and  of  other  secretions.  The  longer 
the  cooking  at  a  proper  temperature  is  continued  the  greater 
are  the  changes  in  the  starch  and  the  better  the  prospect  of 
its  speedy  conversion.  The  conversion  is  effected  in  the  first 
instance  by  the  ptyalin  of  the  saliva,  and  this  under  favour- 
able conditions  acts  with  vigour  and  promptness,  converting 
the  disintegrated  but  insoluble  starch  into  soluble  starch, 
a  long  chain  of  dextrins,  and  finally  into  maltose.     This 


48  THE   STOMACH 

amylolytic  process  continues  in  the  stomach  until  by  the 
pouring  out  of  hydrochloric  acid  the  gastric  contents  acquire 
an  acidity  of  o"oo3  per  cent,  according  to  Chittenden  and 
Smith.  At  all  events  when  the  acidity  reaches  a  certain 
degree  the  digestion  of  starch  ceases,  but  the  digestion  of 
proteins,  which  has  already  begun,  is  accelerated  by  the  in- 
creasing secretion  of  hydrochloric  acid  and  pepsinogen. 
These  three  chemical  phenomena — starch  digestion,  arrest  of 
starch  digestion,  protein  digestion — are  those  upon  which  the 
unconscious  comfort  or  the  conscious  discomfort  of  digestion 
primarily  and  essentially  depends.  When  the  chemical 
equilibrium  and  balance  during  this  period  is  maintained 
the  stomach  works  without  obtruding  its  existence  on  our 
notice.  The  full  significance  of  this  equilibrium  has,  how- 
ever, to  be  realized ;  it  means  the  existence  of  a  "  correct 
relation  "  between  the  amount  of  protein  food  and  the 
amount  of  gastric  secretion.  There  ought  to  be  no  more 
gastric  juice  poured  out  than  can  satisfy  the  needs  of — that 
is,  can  be  taken  up  by — the  protein.  When  this  is  satisfied, 
the  secretion  of  gastric  juice  ought  to  cease,  and  we 
cannot  doubt  that  under  normal  conditions  this  must 
be  the  case.  If  this  arrest  of  secretion  does  not  occur, 
equilibrium  is  upset,  and  the  resulting  perturbation  depends 
upon  the  measure  of  the  excess.  The  element  in  the  secretion 
which  is  the  disturbing  factor  is  the  hydrochloric  acid,  and 
not  the  special  enzyme.  The  effect  of  this  hyperchlorhydria 
upon  the  gastric  contents  is  noteworthy,  and  requires 
explanation.  The  protein  elements  of  the  food  are  digested 
with  promptness  and  even  with  exceptional  alacrity  ;  and  it 
might  be  thought  that  the  other  food  substances,  especially 
the  finely-divided  starch  food,  as  bread  and  oatmeal  porridge, 
would  readily  pass  out  of  the  stomach  with  the  digested  pro- 
teins, but  this  is  not  what  happens.  What  does  occur  is  that 
a  considerable  portion  of  unaltered  starch  is  kept  back  and 
retained  in  the  stomach.  This  I  have  frequently  found 
to  be  the  case.  The  effect  of  this  retained  and  unaltered 
starch  is  to  keep  up  the  gastric  secretion  while  presenting 
no  constituent  with  which  it  can  combine.     The  physiological 


EXPLANATION   OF  THE   SYMPTOMS  49 

concept  is  that  the  undigested  starch  is  readily  passed 
into  the  duodenum,  and  its  digestion  completed  in  the 
intestine.  Even  in  such  conditions  as  I  am  now  con- 
sidering, the  undigested  starch  is,  as  a  rule,  ultimately 
passed  on,  but  this  only  after  much  local  and  often  general  dis- 
comfort ;  but  it  may  be  finally  rejected  by  vomiting.  Another 
interesting  observation  I  have  made  in  this  connection  is  that 
not  only  the  unaltered  starch  may  be  thus  retained,  but  a 
considerable  amount  of  the  fat  of  milk  may  also  be  retained. 
I  have  several  times  noted  this  when  all  the  casein  of  the 
milk  had  disappeared.  I  have  seen  this  both  when  plain  milk 
or  peptonized  milk  had  been  taken.  When  it  occurs  the  fat 
of  the  milk  is  found  diffused  through  the  acid  fluid  removed 
from  the  stomach,  but  partly  floating  upon  it,  presenting  an 
appearance  as  if  it  were  a  mass  of  mucus.  When  the  fat  of 
milk  is  thus  retained,  it  seems  to  me  that  it  also  keeps  up  the 
gastric  secretion,  and,  presenting  no  element  with  which  the 
hydrochloric  acid  can  combine,  the  discomforts  of  hyperchlor- 
hydria  emerge.  A  third  important  factor  in  determining  the 
severity  of  the  symptoms  is  the  kind  of  protein  food  taken. 
The  general  law  is  that  the  less  stimulating  and  the  more 
easily  digested  proteins  cause  less  discomfort  than  do  those 
of  a  contrary  character. 

In  all  three  conditions  there  is  the  common  factor  of  con- 
tinued gastric  secretion,  continued  beyond  what  is  required, 
therefore  beyond  what  can  be  utilized.  This  continued  secre- 
tion, when  the  stomach  contents  are  examined,  provides 
marked  evidence  of  free  hydrochloric  acid,  and  a  high  per- 
centage of  acidity.  At  this  stage  the  stomach  contents  may 
only  measure  from  one  to  a  few  ounces  of  very  acrid  material, 
mainly  fluid,  containing  starch,  some  milk  fat,  and  shreds  of 
undigested  material  according  to  the  kind  of  food  which  had 
been  taken.  The  main  residue  in  ordinary  cases  is  starch. 
At  this  period  the  gastric  s3niiptoms  are  very  severe,  and  I 
have  frequently  obtained  the  contents  of  the  organ  when  the 
symptoms  were  at  their  height,  and  have  been  amazed  at  the 
smallness  of  the  amount  in  view  of  the  intensity  of  the 
symptoms.     Why  a   residuum   of   finely  divided   although 

4 


50  THE  STOMACH 

undigested  starch  should  remain  in  the  stomach  when  other 
material  has  passed  the  pylorus  is  difficult  to  explain.  The 
physiological  position  is  roughly  this,  that  the  fate  of  starch 
in  the  stomach  is  of  relatively  little  importance,  as  it  is 
digested  in  the  intestine  ;  and  this,  from  the  nutritive  stand- 
point alone,  is  true,  and  explains  the  fact  that  sufferers  from 
hyperchylia  do  not  lose  flesh  unless  they  adopt  a  starvation 
policy  in  regard  to  their  food.  But  this  physiological  truth 
is  one  of  those  truths  which  has  led  to  a  total  misapprehension 
of  the  phenomena  of  disordered  function  such  as  the  physician 
has  to  deal  with.  The  interpretation  which  seems  to  me 
to  be  in  accord  with  clinical  observations  is  that  we  have 
to  acknowledge  that  the  unaltered  starch  is  delayed  in  the 
stomach,  and  that  it  is  so  even  when  broken  up  and  digested 
proteins  have  escaped.  Being  thus  delayed  it  continues 
to  stimulate  the  gastric  secretion,  and  there  being  no  more 
protein  with  which  to  combine  the  secretion  accumulates  and 
leads  to  the  hyperacidity  in  question.  That  this  hyper- 
acidity is  due  to  a  true  hypersecretion  is  proved  by  the  great 
peptonizing  power  of  the  filtered  contents  when  tested  in  the 
usual  way.  Once  the  residuum  in  the  stomach  becomes 
hyperacid  its  continued  retention  is  explained  by  the  fact 
that  the  hyperacidity  keeps  the  pyloric  sphincter  closed,  or 
even  causes  spasm  of  it. 

An  Acid  Dyscrasia. — Looking,  in  the  next  place,  at  the 
etiology  of  hyperchylia,  we  find  ourselves  face  to  face 
with  terms  and  designations  which  only  obscure  the  position. 
The  favourite  place  in  which  to  find  it  described  is  under 
gastric  neuroses,  nervous  dyspepsia,  gastric  irritation,  gastro- 
dynia,  or  gastralgia.  It  is  not  always  clear  what  writers  on 
gastric  disorders  mean  by  some  of  these  terms.  Whether 
the  idea  which  is  sought  to  be  conveyed  is  that  the  pain  and 
discomfort  are  merely  subj  ective  nervous  phenomena,  or  that 
an  assumed  neurotic  diathesis  determines  an  increased  secre- 
tion of  hydrochloric  acid.  The  underlying  idea  seems  to  be 
that  the  nervous  mechanism  is  the  part  of  the  system  which 
is  primarily  deranged.  This  conception  I  hold  to  be  erroneous 
and  brimful  of  evil  consequences.     We  all  possess  a  nervous 


OTHER   DETERMINING   CAUSES  51 

system,  some  more  finely  tuned  and  more  responsive  than 
others,  and  we  all  grant  and  recognize  the  important  role 
played  by  it.  All  deviations  of  secretion  from  an  average  stan- 
dard, aU  increases  of  secretion,  all  modifications  of  chemico- 
vital  reaction,  are  not  to-day  accepted  as  explained  or  defined 
by  the  word  "  neurotic,"  and  it  is  time  that  the  word  and  the 
idea  were  relegated  to  a  less  prominent  place  when  consider- 
ing disturbances  of  stomach  function.  In  opposition  to  this 
neiurotic  view  I  would  submit  as  a  result  of  clinical  experi- 
ence and  the  examination  of  gastric  contents  that  certain 
persons  are  prone  to  secrete  over-much  gastric  juice,  and  that 
the  constituent  which  is  primarily  at  fault  is  the  hydro- 
chloric acid.  I  have  been  impressed  with  the  occurrence 
of  severe  hyperacidity  in  some  gouty  and  rheumatic  subjects, 
and  by  its  occurrence  in  some  persons  as  a  consequence  of  a 
diet  rich  in  nitrogenous  substances.  I  think,  indeed,  there  is 
little  doubt  that  we  might  add  to  our  list  of  constitutional 
conditions  an  acid  dyscmsia.  To  regard  the  intense  misery 
of  severe  hyperchylia  as  a  mere  neurosis  is  an  impertinence  to 
some  of  the  victims  of  the  condition.  Apart,  however, 
from  that  aspect  of  the  case  I  hold  the  merely  neurotic  view 
to  be  disproved  by  the  following  phenomena  which  are 
frequently  observed  :  the  instantaneous  relief  obtained  by 
removing  an  ounce  or  two  of  acrid  stomach  residuum  ;  a  like 
relief  obtained  by  neutralizing  the  acid  by  means  of  alkalies  ; 
and  the  measure  of  relief  obtained  by  mere  dilution.  That 
the  over-secretion  is  more  a  chemical  and  a  diathetic  error 
than  a  neurosis  is  further  strongly  supported  by  the  ex- 
perience that  the  mechanical  removal  of  the  hyperacid 
residuum  in  severe  cases  more  promptly  overcomes  the  attack 
than  any  dietetic  or  medicinal  measure — as  if  the  removal  of 
the  acid  removed  an  overflow  which  otherwise  is  difficult  to 
arrest,  and  which  when  not  removed  looks  as  if  it  were 
absorbed  and  again  and  again  resecreted. 

Other  Immediate  Determining  Causes.— While  an  acid 
dyscrasia  is  held  to  be  the  foundation  of  hyperacidity, 
there  are  determining  causes  which  must  at  least  be 
enumerated.     They  are,   in  addition  to  unsuitable  feeding 


52  THE  STOMACH 

or  drinking,  (i)  worry  or  anxiety,  (2)  fatigue,  (3)  chill. 
In  these  respects  it  resembles  gout  and  rheumatism  in 
being  a  pronounced  perturbation  of  chemico-vital  idio- 
syncrasy often  determined  by  nervous  influences.  It  is  the 
influence  of  these  factors  which  presumably  led  to  erroneous 
conceptions  of  its  nature.  As  will  be  seen  later,  it  is  the 
upset  of  chemical  balance  which  determines  the  symptoms, 
and  it  is  only  by  the  recognition  of  this  fact  that  a  true 
understanding  of  the  condition  is  attained  and  a  successful 
therapy  can  be  applied. 

Additional  Comments.  —  While  the  symptoms,  and  the 
time  of  their  appearance,  in  the  most  typical  cases,  are  as 
stated,  they  must  not  be  taken  too  rigidly.  In  medicine 
symptoms  do  not  necessarily  hold  that  place.  The  two 
points  upon  which  emphasis  has  been  laid  are  (i)  pain,  and 
(2)  the  time  it  comes  on  after  a  meal.  With  regard  to  the 
first  of  these,  namely,  pain,  it  varies  greatly  in  intensity. 
In  the  third  and  fourth  decades  of  life  there  may  be,  and 
there  often  is,  no  definite  pain  ;  a  feeling  of  discomfort 
referred  to  the  stomach,  and  perhaps  accompanied  by  a 
general  feeling  of  being  "  out  of  sorts,"  may  be  the  complaint. 
In  the  further  decades  the  tendency  is  for  the  discomfort 
to  be  described  definitely  as  pain.  Instead  of  pain  the 
discomfort  may  be  a  complaint  of  heartburn,  or  of  acid 
eructations,  or  of  both  together.  These  have  been  long 
known  as  gastric  acidity,  or  as  acid  dyspepsia  ;  even  before 
it  was  known  that  the  acidity  was  due  to  over  activity  of 
certain  glands  in  the  stomach.  Pain,  on  the  other  hand,  is 
often  present  without  any  history  of  heartburn  or  of  acid 
eructations,  and  no  doubt  it  was  to  this  condition  that  such 
terms  as  gastralgia,  nervous  dyspepsia,  or  even  neuralgia 
of  the  stomach,  were  applied.  The  second  point  is  the  time 
after  food  when  the  pain  or  discomfort  or  the  heartburn 
appears.  The  pain  or  discomfort  is  what  the  late  Professor 
Wyllie  called  a  "  delayed  pain,"  meaning  thereby  to 
give  it  a  place  distinct  from  the  pain  that  comes  on  in 
other  stomach  disorders  immediately  after  or  soon  after 
taking  food.     The  time  of  onset  of  pain  or  discomfort  in 


ADDITIONAL   COMMENTS  53 

hyperchlorhydria  is  always  some  time  after  a  meal ;  it  is 
usually  an  hour  or  more,  the  time  being  determined  by 
the  kind  of  meal  and  the  size  of  the  meal.  A  large  meal 
of  porridge  and  milk  may  be  foUowed  by  marked  acidity 
in  an  hour  or  even  less.  A  breakfast  of  fish  or  bacon  and 
egg  may  be  followed  by  discomfort  or  pain  in  an  hour 
and  a  half  or  two  hours.  A  large  protein  meal  at  dinner 
time  may  not  give  rise  to  discomfort  for  over  two  hours  or 
even  three. 

With  regard  to  examination  of  the  tongue,  it  is  usually 
clean  but  it  may  be  furred.  It  is  not  coated  as  it  commonly 
is  in  hypochlorhydria.  Constipation  is  the  rule,  but  there 
may  be  a  history  of  daily  and  free  bowel  evacuation.  I  have 
only  met  with  one  case  of  diarrhoea.  In  that  case  the 
complaint  was  diarrhoea  which  was  very  troublesome,  because 
of  uncertainty  as  to  when  an  imperative  demand  might 
arise  to  go  to  stool.  At  our  first  interview  it  was  difficult 
to  find  a  cause  for  this.  The  diet  and  habits  were  above 
suspicion,  but  I  found  the  stomach  dilated  and  splashing,  and 
a  specimen  removed  by  the  tube  showed  much  free  hydro- 
chloric acid.  The  matter  was  explained  to  the  patient  and 
belladonna  and  bicarbonate  of  soda  were  given,  with  the 
result  that  the  diarrhoea  and  the  irregular  and  imperative 
calls  were  quite  relieved. 

The  term  "  paroxysmal  pyrosis  "  has  been  referred  to  at 
page  47,  as  used  by  the  late  Sir  William  Roberts  in  his 
valuable  work  on  Digestion  and  Diet.  He  defines  it  thus  : 
"  This  symptom  consists  in  a  paroxysm,  of  which  the  chief 
features  are  sudden  cramp  of  the  stomach,  with  profuse 
salivation."  He  says  that  writers  on  dyspepsia  exhibit 
confusion  in  the  use  of  the  term,  and  suggests  that  the  term 
should  be  confined  to  these  essentially  characteristic  attacks. 
The  present  writer  leans  to  the  explanation  that  what 
Roberts  thought  was  a  "  sudden  cramp  of  the  stomach  " 
is  a  sudden  relaxation  of  pyloric  spasm  and  either  the  passage 
of  highly  acid  stomach  contents  into  the  duodenum  or  of 
alkaline  duodenal  contents  into  the  acid  stomach  contents. 
However  that  part  of  the  phenomena  is  to  be  explained, 


54  THE   STOMACH 

the  concomitant  profuse  salivation  is  the  result  evidently 
of  a  powerful  reflex  stimulation  of  the  alkaline  secretion  of 
the  salivary  glands  which  could  be  regarded  as  beneficent 
were  the  secretion  swallowed  instead  of  being  ejected  from 
the  mouth.  The  salivary  secretion  in  these  circumstances 
is,  according  to  Roberts,  characterized  "  by  its  unusual 
degree  of  alkalescence."  At  the  time  of  writing  the  case  of 
a  patient,  recently  under  my  care,  suggests  such  an 
association.  The  patient,  a  retired  army  officer,  had  suffered 
from  slight  cough  and  very  copious  expectoration,  which 
annoyed  him  all  day  and  disturbed  him  all  night.  He  was 
thought  to  have  bronchiectasis.  The  expectoration  might 
amount  to  eight  or  ten  ounces  during  the  night.  It  con- 
sisted of  a  clear  viscous  fluid  with  lumps  of  white  mucous 
floating  on  the  top.  There  was  no  evidence  of  anything 
being  wrong  in  the  respiratory  organs  save  very  trifling 
catarrh  in  the  bronchi.  The  appearance  of  the  expectorated 
material  at  once  suggested  salivation,  and  fuller  examination 
showed  it  to  be  alkaline  in  reaction  and  to  contain  diastasic 
ferment.  It  was,  in  fact,  typical  salivary  gland  secretion. 
Dr.  Logan  Turner  found  nothing  in  the  throat  or  posterior 
nares  to  explain  the  condition.  There  were  no  symptoms  of 
gastric  hyperacidity,  but  as  the  patient  was  rheumatic  and 
gouty  it  was  decided  to  add  bicarbonate  of  soda  to  the 
belladonna  which  was  clearly  indicated.  Under  ten  minims 
of  tincture  of  belladonna  and  twenty  grains  of  bicarbonate 
of  soda  thrice  daily  the  secretion  rapidly  fell  in  volume  and 
finally  became  normal.  Whether  the  "  profuse  salivation  " 
can  be  associated  in  this  case  with  the  same  "  acid  dyscrasia  " 
as  we  hold  gastric  hyperchlorhydria  to  be  associated  with, 
may  be  questioned ;  but  the  case  is  referred  to  here  as 
suggestive,  although  it  is,  in  the  writer's  knowledge,  unique. 

Illustrative  Cases 

A.  Acute  Cases.  —  The  symptoms  of  hyperchlorhydria 
not  infrequently  come  on  somewhat  acutely  in  strong 
vigorous  persons  who  have  not  suffered  previously  from 


ILLUSTRATIVE   CASES  55 

digestive  disturbance  of  any  kind.     As  examples  of  this  the 
following  cases  arc  given. 

Case  5.— A  gentleman,  aged  37,  who  was  sent  to  me 
in  November,  had  suffered  for  one  month  from  pain  and 
flatulence.  The  pain  came  on  about  two  hours  after  break- 
fast, two  hours  after  lunch,  and  two  hours  after  an  eight 
o'clock  dinner.  He  had  sometimes  been  wakened  in  the 
night  with  the  pain.  The  pain  lately  had  become  almost 
constant,  but  he  had  noticed  that  taking  food  put  it  away  for 
a  time.  The  bowels  had  been  constipated  from  the  onset 
of  the  symptoms,  and  he  had  for  this  taken  an  occasional 
laxative.  The  tongue  was  furred.  On  examination  of 
the  abdomen,  succussion  showed  the  lower  border  of  the 
stomach  to  be  at  the  level  of  the  umbilicus.  There  was 
nothing  to  note  in  his  other  systems.  He  had  no  worries, 
and  he  led  the  open-air  life  of  a  country  gentleman.  "  Indi- 
gestion was  common  in  his  family,  and  his  father  died 
of  it." 

I  advised  a  considerable  reduction  in  the  amount  of  food, 
wine,  and  malt  liquor  he  was  taking,  and  gave  him  belladonna 
and  soda  to  take  thrice  daily.  He  saw  me  again  at  the  end  of 
a  week  and  of  a  fortnight ;  he  had  had  no  pain  since  he  began 
the  medicine,  and  by  the  latter  date  the  dilatation  of  the 
stomach  had  entirely  disappeared.  He  remained  perfectly 
well,  and  has  had  no  return  of  his  symptoms  up  to  the 
present  time. 

Case  6.  —  A  retired  officer  of  the  R.A.M.C,  aged  54, 
consulted  me  in  August.  He  had  been  attacked  by  pain 
between  three  and  four  weeks  before,  two  hours  or  more 
after  lunch,  and  it  had  lasted  for  a  couple  of  hours.  This 
pain  kept  recurring  about  two  hours  after  taking  food.  He 
dieted  himself  very  strictly,  and  found  that  the  pain  kept 
away  if  he  lived  on  milk,  biscuits,  and  lightly  boiled  eggs. 
He  was,  as  a  result  of  this  meagre  diet,  getting  weak  and  out 
of  condition.  The  pain  sometimes  kept  him  awake  at  night. 
He  found  that  taking  hot  milk  removed  the  pain.  The 
stomach  was  not  dilated.  There  were  no  further  points  I 
need  refer  to. 


56  THE  STOMACH 

I  gave  the  patient  belladonna  and  sodium  bicarbonate, 
and  a  laxative  pill  of  cascara,  belladonna,  and  nux  vomica  ;  I 
took  off  the  restrictions  on  his  feeding,  but  advised  that  he 
should  have  red  flesh  and  chicken  minced.  The  belladonna 
and  soda  were  to  be  taken  after  food,  as  soon  as  the  discom- 
fort began.  He  reported  himself  to  me  in  the  end  of  Sep- 
tember, and  assured  me  that  the  medicine  had  very  promptly 
removed  his  symptoms. 

He  kindly  reported  himself  in  September  of  the  following 
year,  when  passing  through  Edinburgh,  and  informed  me 
that  he  had  had  occasional  threatenings  of  a  return  of  his 
symptoms,  but  found  that  he  had  the  remedy  in  the  drugs 
I  had  prescribed. 

B.  Cases  of  Longer  Duration. — I  select  the  following  cases 
for  the  illustration  of  this  class. 

Case  7.  —  The  patient  was  a  medical  man,  aged  47, 
who  consulted  me  in  June.  He  had  suffered  off  and  on 
with  acidity  for  twenty  years.  The  attack  from  which  he 
was  suffering  when  he  came  to  me  had  lasted  for  two  weeks, 
and  was  unusually  severe.  Pain  came  on  about  two  hours 
after  food,  and  might  continue  up  to  the  taking  of  the  next 
meal ;  taking  food  relieved  the  pain.  There  was  no  vomiting, 
and  the  bowels  m  oved  daily  and  freely.  There  was  no  gastric 
dilatation,  but  as  there  was  something  in  his  stomach 
it  was  drawn  off,  and  was  found  to  be  intensely  acid  from 
free  HCl,  while  the  material  removed  consisted  of  fluid  and 
starch.  The  diet  was  regulated,  and  I  recommended 
belladonna  before  food  and  bicarbonate  of  soda  after  food, 
as  soon  as  the  pain  threatened.  Ten  days  later  he  wrote 
saying  how  much  better  he  was,  and  that,  "  although  the 
weather  has  been  simply  atrocious,  I  have  not  suffered  any 
more."  Three  years  later  he  assured  me  that  he  had  been 
able  to  restrain  his  old  enemy  as  soon  as  there  was  a  threaten- 
ing of  reappearance.  He  scouted  any  suggestion  of  having 
either  a  gastric  or  a  duodenal  ulcer. 

Case  7a. — Another  medical  man,  aged  35,  consulted  me  in 
November.  He  had  not  suffered  so  long  as  our  preceding 
friend,  but  was  finding  his  energy  sapped  and  life  burdened 


EFFECTS   OR   COMPLICATIONS  57 

by  his  recurring  attacks.     He  was  cured,  and  has  become 
an  able  exponent  of  the  chnical  manifestations  of  hyper- 
chlorhydria,  and  a  curer  of  the  condition  in  others. 
These  cases  occurred  in  medical  men. 

Effects  or  Complications 

The  effects  or  results  of  h}'perchlorhydria  have  now 
to  be  considered.  They  may  be  regarded  as  complica- 
tions, in  the  sense  that  they  constitute  what  have  been 
regarded  hitherto  as  separate  or  independent  conditions. 
The  view  here  taken  is  that  so-called  complications  have 
their  origin  in  disturbance  of  normal  gastric  secretion 
and  are  the  result  of  that  disturbance.  This  gives  aberra- 
tion of  function  its  true  position,  as  the  forerunner  of 
anatomical  changes,  and  accentuates  the  importance  of 
recognizing  such  aberrations  from  the  supreme  stand- 
point of  preventive  medicine.  Accepting  this  proposition, 
the  fact  that  functional  disturbance  is  of  two  kinds,  and  that 
each  is  amenable  to  intelligent  treatment,  puts  gastric 
disorders  in  a  much  simpler  light  than  they  have  been 
regarded  hitherto.  Not  only  this  but  it  puts  in  the  hands  of 
the  practitioner  the  means  of  preventing  the  development 
of  some  of  the  most  disabling  maladies  to  which  civilized 
man  is  liable. 

These  are  (i)  Pyloric  spasm,  (2)  Atonicity  and  dilatation, 
(3)  Ptosis,  (4)  Ulceration,  and  they  will  be  considered  in  thai 
order. 

(i)  Pyloric  Spasm. — It  has  been  pointed  out  that  the 
pain  in  h3,'perchlorhydria  is  due  to  pyloric  spasm.  This 
spasm  may  not  be  confined  to  the  sphincter  of  the  pylorus, 
but  may  involve  more  or  less  of  the  pyloric  antrum.  If  the 
abdominal  wall  is  thin  and  the  abdomen  easily  palpated, 
as  it  often  is  in  these  cases,  the  portion  in  spasm  can  occa- 
sionally be  felt  and  has  frequently  been  diagnosed  as  pyloric 
neoplasm.  It  is,  however,  only  palpable  when  pain  is 
present,  and  cannot  be  felt  in  the  intervals  of  pain. 

(2)  Atonicity  and  Dilatation. — In  severe  cases  of  hyper- 
chlorhydria,  which  have  lasted  for  some  time,  the  stomach 


58  THE   STOMACH 

presents  varying  degrees  of  atonicity  and  of  dilatation, 
The  atonicity  is  tlie  result  of  undue  retention  of  food  due  to 
pyloric  spasm  ;  the  musculature  of  the  stomach  wall  be- 
comes exhausted,  and  exhaustion  of  involuntary  muscle 
always  implies  relaxation  and  consequent  dilatation.  This 
is  one  of  the  forms  of  atonic  dilatation  and  the  tendency 
is  towards  steady  increase  in  the  degree  of  dilatation  and 
atonicity. 

(3)  Ptosis.— Ptosis  of  the  greater  curve  of  the  stomach, 
or  of  both  it  and  the  lesser  curve,  may  result  from  long- 
continued  or  frequently  recurring  attacks  of  hyperchlor- 
hydria.  The  phenomena  produced  will  be  dealt  with 
under  the  special  heading  of  "  The  Position  of  the  Stomach." 

(4)  Ulceration.  —  The  occurrence  of  gastric  and  pyloric 
ulceration  will  be  dealt  with  in  special  sections. 


CHAPTER  VI 

AIR-SWALLOWING  :    COMMONLY   CALLED   FLATULENT 
DYSPEPSIA 

Air-gulping  is  a  fairly  widely  recognized  condition.  It  is 
characterized  and  known  not  so  much  by  the  air-gulping 
as  by  the  great  distension  it  may  cause  or  by  the  great 
belching  up  of  wind  from  time  to  time.  About  twelve 
years  ago  I  had  an  extremely  pronounced  case  of  this  kind 
in  the  Infirmarj^  The  patient  was  a  girl  in  her  'teens  and 
the  story  we  got  was  that  the  belching  was  so  loud  that  the 
neighbours  heard  the  noise.  WTien  the  case  was  being  read 
at  the  bedside  I  noticed  that  she  kept  steadily  swallowing 
air  and  when  discoursing  to  the  students  on  the  condition 
had  no  difficulty  in  getting  the  patient  to  blow  up  her 
stomach  by  gulping  air  and  then  to  belch  it  up.  In  animals 
the  condition  is  known  as  "  air-sucking ;  "  it  occurs  in 
cattle  and  horses,  and  in  them  it  is  a  very  serious  condition 
which  may  cause  death. 

The  term  "  air-swallowing  "  I  have  used  for  the  swallow- 
ing of  air  when  food  is  swallowed.  This  is  a  common 
condition  and  yet  it  is  not  generally  recognized.  Although 
it  occurs  specially  when  food  is  being  taken  it  may  be 
continued  during  the  period  of  gastric  digestion,  especially 
if  there  be  digestive  disorder.  The  amount  swallowed 
varies  in  individual  instances,  and  therefore  the  degree 
of  distension  and  of  consequent  discomfort  caused  by  it 
varies.  In  some  patients  discomfort  is  great  because  the 
amount  swallowed  is  large.  It  may  be  so  great  as  to  give 
rise   to   visible   distension ;     it   maj-    lead   to   pronounced 

59 


6o  THE   STOMACH 

neurasthenia,  and  to  grave  mental  depression ;  it  may 
act  reflexly  on  heart  and  vessels,  leading  to  functional 
angina  pectoris.  It  may  not  only  be  associated  with,  but 
apparently  may  be  caused  by,  abnormal  gastric  secretion, 
abnormal  in  the  sense  of  the  secretion  containing  too  much 
or  too  little  hydrochloric  acid.  In  my  experience  it  is 
more  common  and  more  pronounced  in  the  latter,  that  is, 
in  hypochlorhydria.  While  it  occurs  in  both  conditions, 
it  also  occurs  independently  of  either,  when  it  has  to  -be 
regarded  as  an  unfortunate  faculty.  It  occurs  in  both 
sexes  and  is  probably  fairly  common  in  children.  \Mien 
the  condition  is  present  it  can  be  demonstrated  on  the 
screen,  but  the  most  pronounced  cases  give  the  most  striking 
picture. 

The  more  extreme  cases  are  not  very  common,  and  a 
proportion  of  the  cases  seen  have  been  seen  in  consultation, 
where  the  cause  of  the  symptoms  had  not  been  recognized. 

The  following  cases  illustrate  the  symptoms  and  the 
phenomena  which  are  present. 

Illustrative  Cases  of  Air-swallowixg 

Case  8. — This  man,  J.  I.,  aged  30,  was  sent  to  I\Ir. 
Cathcart  with  a  view  to  surgical  treatment.  'Mr.  Cathcart 
did  not  think  him  a  suitable  case  for  operation  and  asked 
me  to  admit  him  to  my  ward.  He  was  transferred  on  the 
3rd  November,  1915.  The  history  we  got  was  that  he 
had  enlisted  on  the  outbreak  of  war,  that  he  served  in 
Flanders,  and  was  discharged  in  June,  1915,  for  "  total 
disablement."  In  April  he  began  to  have  attacks  of  very 
severe  pain  in  the  epigastrium.  The  pain  came  on  after 
food,  lasted  for  several  hours,  and  was  often  followed  by 
vomiting.  The  vomiting  did  not  as  a  rule  relieve  the 
pain.  He  lost  appetite,  became  weak  and  sometimes  giddy. 
Restricting  his  diet  alleviated  the  symptoms.  He  was  in 
an  English  county  hospital  for  a  time  and  from  that  hospital 
was  discharged  from  the  army.  He  returned  to  his  home  in 
cotland  and  sta3'ed  in  bed  for  five  weeks,  taking  liquid 


ILLUSTRATIVE  CASES  OF  AIR-SWALLOWING    6i 

nourishment.  Then  he  was  sent  to  a  convalescent  hospital, 
where  his  stomach  was  washed  out  twice  a  day,  with  slight 
improvement  in  his  symptoms.  It  was  from  this  hospital 
that  he  was  sent  to  the  Edinburgh  Royal  Infirmary  for 
admission  to  Mr.  Cathcart's  wards  with  a  view  to 
operation. 

On  asking  him  carefully  about  his  symptoms,  it  was 
brought  out  that  immediately  after  taking  food  he  had  the 
feeling  of  being  greatly  blown-up,  and  that  the  feeling  of 
fullness  and  distension  came  up  his  chest  into  his  throat. 
On  examination  the  abdomen  was  distended,  the  distension 
being  forwards.  There  were  no  peristaltic  movements 
visible  ;  there  was  some  tenderness  in  the  epigastrium  and 
in  the  right  iliac  region,  but  palpation  was  unsatisfactory 
in  its  results  as  the  abdominal  wall  was  made  tense  as  soon 
as  it  was  touched,  the  patient  at  the  same  time  holding 
his  breath  and  arching  his  back.  Immediately  after  a 
meal  the  area  of  stomach  tympanicity  was  increased. 

Remarks. — This  case  in  the  first  place  illustrates  the 
value  of  careful  and  critical  sifting  of  symptoms  in  abdominal 
work.  The  patient  was  quite  confident  that  the  sense  of 
fullness  and  distension  came  on  immediately  after  taking 
food  of  any  kind,  and  of  its  rapidly  becoming  so  extreme 
as  to  come  up  into  his  throat  as  if  it  would  choke  him.  Now 
no  gastric  lesion  or  disorder  of  gastric  function  causes 
symptoms  like  these ;  gastric  ulcer,  gastric  carcinoma, 
hyperchlorhydria,  or  other  functional  disorder  never  give 
rise  to  the  symptom  which  with  care  was  fully  established 
as  present  in  this  patient.  That  being  so,  the  next  step 
towards  a  diagnosis  was  determined  by  former  experience, 
and  the  simple  explanation  offered  itself  that  the  patient 
was  an  air-swallower,  that  he  swallowed  air  while  taking 
food  and  probably  for  some  time  after.  By  submitting 
him  to  X-ray  examination  we  were  able  at  once  to  confirm 
this  opinion.  Dr.  Hope  Fowler  kindly  carried  out  the 
examination  in  our  presence.  The  bismuth  as  it  was 
swallowed  passed  into  the  dependent  part  of  the  stomach 
above  the  level  of  the  umbilicus,  while  an  air-space  was  seen 


62  THE   STOMACH 

at  the  fundus ;  as  he  continued  slowly  to  swallow  the 
bismuth,  the  air-space  rapidly  increased  in  size  ;  and  when 
he  M''as  asked  to  swallow  without  bismuth,  the  fundus  of  the 
stomach  was  seen  to  rise  up,  and  the  air  area  to  enlarge 
until  it  attained  the  size  of  an  adult  head.  The  appearance 
was  well  seen  in  the  plate,  but  it  has  unfortunately  been 
lost.  Now  let  me  impress  upon  you  that  the  patient  did 
not  know  he  was  doing  this.  The  only  way  to  cure  such  a 
case  is  to  explain  to  him  what  he  is  doing,  and  to  tell  him 
that  it  will  require  watchfulness  and  perseverance  to  over- 
come the  habit. 

Abdominal  Rigidity  in  Air-swallowing.  —  Mention  has 
been  made  in  the  preceding  case  of  the  difficulty  in 
palpation  of  the  abdomen  owing  to  the  abdominal  muscles 
becoming  tense  when  the  abdomen  was  touched.  It  was 
difficult  at  the  time  to  refrain  from  thinking  that  it  was  due 
to  a  volitional  act,  although  one  did  not  see  what  motive 
could  underlie  it.  Its  presence  was  striking  and  it  was 
invariably  produced.  Quite  recently  I  have  again  seen  this 
phenomenon.  The  patient  was  seen  in  my  consulting 
room  by  appointment.  He  had  travelled  twenty  miles. 
He  was  seen  at  2  p.m.,  and  he  had  breakfasted  at  9.30  a.m. 
He  had  suffered  considerably  from  his  stomach  for  two 
years,  with  intervals  of  relief.  The  history  in  part  suggested 
hyperacidity,  but  in  parts  this  was  obscured;  in  short, 
symptoms  were  rather  difficult  to  unravel.  He  stated  that 
on  arriving  in  town  he  had  tried  to  take  a  basin  of  soup, 
but  he  could  not  swallow  it.  He  was  feeling  very  uncom- 
fortable in  the  upper  part  of  the  abdomen,  the  discomfort 
amounting  to  pain.  On  inspection  the  upper  half  of  the 
abdomen  appeared  to  be  full,  and  on  placing  the  hand  on 
it  the  wall  became  rigid.  In  spite  of  every  device  this 
phenomenon  persisted  and  interfered  with  exploration  of 
the  abdominal  regions.  The  prominence  in  the  upper  half 
suggested  a  distended  stomach,  and  on  percussion  there 
was  a  low-pitched  tympanicity  over  it.  No  splasli  could 
be  obtained.  The  patient  was  then  given  a  tumblerful  of 
hot  water  to  drink,  after  which,  by  means  of  the  binaural 


ILLUSTRATIVE  CASES  OF  AIR-SWALLOWITsG    63 

stethoscope,  a  fine  tinkle  was  heard  clearly  produced  in 
a  resonating  air-chamber.  A  stomach  tube  was  passed 
with  its  free  end  placed  in  a  large  basin  of  water.  The 
force  with  which  the  imprisoned  air  escaped  was  very 
great  and  spilt  some  of  the  water  out  of  the  basin.  After 
the  air  had  escaped,  the  residue  of  breakfast  was  recovered 
consisting  of  finely  granular  toast  :  it  was  very  rich  in 
free.  HCl.  This  proceeding  gave  immediate  relief.  The 
swelling  in  the  upper  part  of  the  abdomen  had  disappeared, 
and  its  place  was  represented  by  a  depression.  The  abdomen 
could  be  handled  freely  without  inducing  rigidity.  The 
sequence  of  events  was  recurring  hj-perchlorhydria,  the 
discomfort  of  which  led  to  unconscious  air-swallowing, 
possibly  along  with  a  stimulated  salivary  secretion.  The 
h\'perchlorh3-dria  pain  became  overshadowed  by  the  extra- 
ordinary stomach  distension  and  the  depression  it  caused. 
The  patient  was  a  medical  man  and  the  case  is  used  to 
illustrate  how  easy  it  is  to  misinterpret  even  such  a  phe- 
nomenon as  abdominal  rigidity. 

Case  9. — Mrs.  B.  was  sent  to  me  b}^  a  medical  friend  in 
the  cit}^  as  he  feared  she  had  some  serious  disease  of  the 
stomach.  Her  complaint  was  stomach  discomfort  and  pain. 
When  closely  questioned  about  the  "  pain  "  we  were  able 
to  get  the  time  of  onset  and  the  kind  of  discomfort  defined. 
The  time  of  onset  was  immediately  after  eating,  it  occurred 
after  every  meal,  and  she  had  suffered  from  it  for  months. 
The  kind  of  discomfort  was  ascertained  by  making  certain 
suggestions  to  her.  When  asked  if  the  pain  was  severe  the 
reply  was  negative,  and  when  asked  if  it  were  pain  or  an 
uncomfortable  feeling  of  tightness  she  readily  replied  that 
it  was  a  great  tightness  and  fullness.  On  this  definition 
she  became  quite  clear  and  decisive.  As  to  the  duration  of 
the  feeling  she  thought  the  time  varied.  Asked  if  she 
brought  up  much  wind,  the  reply  was  that  she  brought  up 
"  a  lot  of  wind,"  and  she  was  quite  sure  that  the  bringing 
up  of  the  wind  gave  her  prompt  relief.  In  other  respects 
the  digestive  sj^stem  presented  no  abnormal  symptoms  ; 
but  she  was  emphatic  as  to  the  discomfort,  anxiety,  and 


64  THE  STOMACH 

depression  the  stomach  condition  caused.  Nothing  abnormal 
was  made  out  on  examination  of  the  abdomen  ;  there  was 
no  stomach  enlargement  or  ptosis,  no  tenderness  at  the 
caecum  or  elsewhere.  The  abdomen  was  lax  and  easily 
explored. 

Such  were  the  facts  obtained  by  a  carefully  elicited 
history  and  from  physical  examination.  Note  specially 
the  onset  of  the  symptom  of  "  pain,"  which  was  eon- 
verted  into  "  fullness  and  tightness,"  coming  on  with 
the  taking  of  food,  increasing  as  food  was  swallowed,  until 
eating  was  stopped  owing  to  the  feeling  of  "  fullness  " — no 
more  could  be  swallowed.  The  history  in  this  case  is 
quite  different  from  the  history  obtainable  in  a  case  of 
gastric  ulcer,  which  is  the  only  condition  with  which  it 
might  be  confused,  if  the  history  of  the  symptoms  were  not 
carefully  and  critically  examined.  The  statement  of  the 
onset  of  pain  "  immediately  after  food  "  and  of  "  flatulence," 
must  not  be  accepted  at  their  bare  word  value  ;  not  that  a 
patient  means  to  mislead,  but  because  patients  do  not 
understand  the  physiology  of  digestion  and  use  words 
loosely.  A  history  has  to  be  sifted  in  the  light  of  the 
knowledge  of  normal  digestion,  of  the  aberrations  to  which 
digestion  is  liable,  and  of  the  clinical  knowledge  we  have 
acquired  of  these  disorders. 

Case  10. — Mrs.  M.,  aged  42,  had  a  history  of  "  gastric 
ulcers  "  at  the  age  of  22  years.  For  some  weeks  before 
I  saw  her  she  had  suffered  from  stomach  pain  after  food 
and  frequent  vomiting.  She  was  well  nourished  and 
the  colour  was  good.  There  was  a  palpable  swelling  in 
the  epigastrium  which  felt  like  a  thickened  pylorus.  The 
gastric  contents  showed  entire  absence  of  free  HCl.  A  few 
days  in  a  nursing  home  showed  that  there  was  no  pyloric 
obstruction.  She  was  given  dilute  hydrochloric  acid,  milk 
was  stopped,  and  savoury  food  was  given.  The  pain 
and  vomiting  stopped,  but  after  a  few  days  there  was  a 
return  of  discomfort  which  on  careful  questioning  was 
evidently  due  to  air-swallowing,  if  not  to  air-gulping  also. 
An  X-ray  examination  showed  this  view  to  be  correct. 


[To  face  page  65. 


AIR-SWALLOWING— CARDIAC  DEPRESSION    65 

The  condition  was  explained  to  her  and  she  was  instructed 
to  avoid  the  act  of  swallowing  except  when  taking  food. 
She  went  home  and  remained  well  and  learnt  to  recognize 
the  fact  that  there  was  a  tendency  to  gulp  at  certain  times, 
and  that  it  was  difficult  to  resist  doing  so.  She  was  quite 
satisfied  that  she  gulped  air  at  these  times.  Fig.  i  is  of 
this  patient  and  shows  the  air-ball  at  the  fundus  which  had 
appeared  as  the  bismuth  meal  was  being  swallowed. 

Fig.  2  is  introduced  to  illustrate  the  condition  in  a  more 
pronounced  case. 

Air-swallowing  causing  Attacks  of  severe 
Cardiac  Depression 

Case  11  (Mrs.  R.). — ^This  case  is  given  briefly  as  it  illustrates 
the  reflex  effect   the   condition  may  have  upon  the  heart. 
The  patient  was  between  50  and  60  years  of  age.     She  had 
undergone  hysterectomy  some  years  before.     She  had  some 
oedema  of  the  legs,  the  myocardium  was  wanting  in  tone, 
there  was  no  albumin,  and  she  was  considerably  run  down 
and  easily  tired.     In  the  nursing  home  she  had  an  alarming 
attack  of  what  looked  like   collapse.     She  became   pale, 
cold,  and  almost  pulseless,  and  she  felt  very  ill.     She  was 
treated   with   great   promptness   by   means   of   stimulants 
and  heat  and  recovered.     She  informed  us  that  she  was 
subject  to  attacks  of  this  kind.     On  special  inquiry  it  was 
ascertained    that    the    symptoms    disappeared    when    she 
brought    up  a  lot   of    wind.      She    stated   that    this    had 
occurred  in  other  attacks.     From  this  it  was  evident  that 
our  patient  was  an  air-gulper,  and  that  this  was  the  explana- 
tion of  the  heart  attacks,  which  had  been  difficult  to  under- 
stand.    The  condition  was  explained  to  her  and  she  was 
asked  to  avoid  swallowing  and  to  note  whether  she  wanted 
to  swallow.     She  was  an  intelligent  and  observant  woman, 
and  she  soon  told  us  that  at  times,  and  particularly  at  night, 
she  felt  as  if  a  ball  were  sticking  in  her  throat,  and  that  she 
made  repeated  efforts  to  get  rid  of  the  feeling  by  swallowing. 
She  had  difficulty  in  preventing  herself  doing  this,  but  her 

5 


66  THE   STOMACH 

common  sense  and  will-power  enabled  her  to  restrain  the 
inclination.  The  result  was  that  the  obscure  heart  attacks 
disappeared. 

Cases  of  this  kind  are  met  with  from  time  to  time  in 
elderly  people,  and,  when  associated  with  a  feeble  myo- 
cardium, the  condition  gives  rise  to  very  alarming  symptoms 
and  may  even  be  fatal.  I  have  known  the  stomach  tube 
used  to  evacuate  the  air  when  it  could  not  be  otherwise 
removed. 

General  Remarks. — Air-swallowing  with  food  is  a  very 
common  condition.  It  occurs  in  all  classes,  and  in  both 
sexes.  The  amount  swallowed  varies  greatly  in  different 
individuals.  The  commonest  manifestation  is  merely  a 
feeling  of  fullness  and  distension,  after  a  meal  very  moderate 
in  quantity,  and  which  passes  off  as  soon  as  the  air  is 
eructated.  The  eructation  is  easily  induced  by  some, 
whilst  in  others  it  is  only  attained  after  a  period  of  much 
discomfort.  In  this  latter  type  of  case  it  is  probable  that 
the  discomfort  leads  to  further  gulping  and  the  eructation 
is  only  accomplished  when  the  fundus  has  attained  a  certain 
degree  of  distension.  In  some  persons  the  mere  act  of 
swallowing  means  air-swallowing.  This  fact  can  be  demon- 
strated by  means  of  the  X-ray  screen.  After  a  bismuth 
meal  has  been  swallowed  in  mouthfuls,  and  the  passage  of 
air  with  it  shown  on  the  screen,  the  patient  is  then  asked  to 
continue  to  perform  the  act  of  swallowing  repeatedly, 
the  increase  in  the  size  of  the  air-ball  at  the  fundus  is  very 
striking  and  can  be  carried  to  quite  an  extraordinary  degree 
of  fundal  distension.  This  unfortunate  faculty  is  possessed 
by  some  young  people. 

The  lesser  and^moderate  forms  are  commonly  described  as 
"  flatulent  dyspepsia,"  the  prevalent  idea  being  that  the 
"  gas  "  is  generated  in  the  stomach.  Prevailing  notions 
of  stomach  fermentation  with  gas  production  is  a  relic  of 
the  crude  conception  we  had  of  stomach  troubles  and  was 
based  upon  the  experiences  of  cases  of  malignant  pyloric 
obstruction. 

The  graver  forms  may  be,  and  often  are,  associated  with 


AIR-SWALLOWING— TREATMENT  67 

grave  nervous  phenomena.  Severe  neurasthenia  and 
inabiUty  for  work  of  any  kind  along  with  great  mental 
depression  are  by  no  means  uncommon.  Their  true  nature 
often  escapes  detection. 

Treatment. — As  regards  treatment  the  first  and  the 
essential  point  is  to  get  the  patient  to  understand  the  cause 
of  the  symptoms.  He  or  she  has  to  be  tactfully  instructed 
and  informed  that  it  is  an  unconscious  act  and  a  faculty 
which  some  persons  possess  and  others  do  not.  The  explana- 
tion of  it  is  not  known,  as  to  the  fact  there  is  no  doubt. 
]\Iitigation  or  cure  can  only  be  effected  with  the  co-operation 
of  the  patient.  A  mixture  containing  valerian,  nux  vomica, 
and  acid  is  helpful. 


CHAPTER  VII 

METHOD   OF    DETERMINING    THE    POSITION    AND    SIZE   OF  THE 
STOMACH    IN   THE    RECUMBENT    POSITION 

The  importance  of  care  and  patience  in  our  endeavours  to 
elicit  the  real  symptoms  of  gastric  and  other  abdominal 
disorders  has  been  already  dealt  with  and  need  not  again  be 
dealt  with  in  detail.  It  is  mentioned  again  as  it  must  never 
be  lost  sight  of  as  the  starting-point  in  the  investigation  of 
practically  all  cases.  The  next  step  is  the  determination  of 
the  position  and  size  of  the  stomach.  The  procedures  to 
be  followed  in  this  investigation  wiU  now  be  described  and 
explained.  In  this,  as  in  many  other  examinations  which 
give  phenomena  based  on  simple  physical  principles,  it  is 
necessary  to  understand  that  we  have  to  learn  not  only  to 
recognize  the  presence  of  certain  phenomena,  but  also  their 
absence.  This  statement  is  understood  when  it  is  realized 
that  the  physical  examination  of  the  stomach  depends  on 
its  being  a  bag-like  viscus,  which  varies  in  size  and  position  ; 
that  it  may  be  empty  with  its  surfaces  in  contact,  or  may 
contain  more  or  less  air,  and  a  greater  or  less  quantity  of 
fluid  or  semi-fluid  material. 

Percussion — Tympanicity. — The  normal  and  empty  stomach 
usually  contains  some  air,  and  when  percussion  is  made  over 
the  air-containing  part,  which  is  at  the  fundus,  a  tympanitic 
note  is  elicited.  This  area,  which  measures  two  to  three 
inches  in  diameter,  is  above  the  costal  margin  on  the  left 
side  in  the  mammary  line,  and  is  known  as  Traube's 
area.  When  the  position  of  this  area  is  determined  the 
exact  extent  of  it  is  found  by  the  size  of  the  area  of 
tympanicity. 

68 


BULGING  AND   PERISTALSIS  69 

Auscultation  and  Scratching. — The  limits  of  the  area 
can  also  be  determined  by  scratching  the  surface  with 
the  finger  nail  while  the  stethoscope  is  applied  over  its 
centre.  The  scratching  sound  is  well  heard  over  the 
tympanitic  area,  but  is  much  diminished  in  intensity,  or 
quite  lost,  when  the  limits  of  the  area  are  passed.  This 
method  is  seldom  of  any  value  in  determining  the  size  or 
position  of  the  viscus  as  a  whole,  for,  when  the  body  of  the 
stomach  is  either  empty  with  its  walls  in  contact,  or  full  of 
food  or  fluid,  the  scratching  sound  is  lost  over  it.  Occasionally, 
with  a  patient  lying  flat  on  the  back,  the  air  in  the  stomach 
may  be  anterior  to  the  stomach  contents  while  they,  on  the 
other  hand,  lie  in  the  more  dependent  and  therefore  the  more 
posterior  part  of  the  viscus.  WThien  these  conditions  are 
present  the  whole  anterior  aspect  of  the  stomach  can  be 
mapped  out  by  careful  percussion  or  by  combined  ausculta- 
tion and  scratching.  It  is,  however,  by  no  means  common 
to  find  this  distribution  of  air  and  fluid  contents.  The 
point  which  has  to  be  realized  is  that  tympanicity  means  that 
the  air-containing  part  of  the  stomach  is  in  contact  with  the 
parietes,  while  the  airless  stomach,  or  the  full  portion  of  the 
viscus,  does  not  give  either  the  tympanitic  note  or  the 
auscultatory  phenomena  mentioned. 

Bulging  and  Peristalsis. — Even  before  percussion  is  used, 
inspection  is  made.  In  normal  conditions  the  stomach  does 
not  reveal  its  position  on  inspection  ;  so  that  here  again 
there  is  an  illustration  of  the  value  of  the  absence  of 
phenomena — what  we  may  call  "  negative  evidence."  On 
the  other  hand,  if  the  stomach  is  visible  by  its  bulging  out 
the  abdominal  wall,  or  if  its  contraction  or  peristalsis  is 
visible,  it  is  frequently  a  sign  of  enlargement  with  some 
difficulty  at  the  pyloric  outlet.  The  stomach  can  hardly 
be  said  to  bulge  out  the  abdominal  wall  except  when  the 
stomach  contracts  upon  its  contents,  but  when  such  con- 
traction occurs  the  abdominal  waU  can  often  be  seen  to  rise 
up  so  that  the  outline  of  the  part  of  the  stomach  in  contact 
with  the  parietes  can  be  readily  outlined.  In  other  cases 
not  only  is  this  bulging  visible,  but  a  quite  definite  peristaltic 


70 


THE   STOMACH 


movement  can  be  seen  to  pass  along  it.  The  position  of  the 
stomach,  of  course,  determines  the  position  of  the  bulging 
and  the  peristalsis — it  may  be  above  or  below  the  level  of 
the  umbilicus.  The  only  part  of  the  abdominal  viscera 
with  which  it  may  be  confused  is  the  transverse  colon,  and 
this  presents  no  serious  difficulty,  for  as  will  be  shown 
presently  other  means  of  examination  can  absolutely 
determine  whether  what  is  visible  is  or  is  not  due  to  stomach. 

If  it  is  not  due  to  stomach 


© 


© 


Fig.  3. — S,  stomach;  TC,  transverse 
colon;  U,  umbilicus;  ^u  anterior 
iliac  spines. 


there  is  usually  no  doubt 
about  its  being  transverse 
colon. 

Stomach  and  Transverse 
Colon. —  Fig.  3  illustrates 
what  is  meant.  In  the 
patient  from  whom  the 
figure  was  taken,  peristalsis 
was  visible  along  the  broken 
line  as  soon  as  the  abdomen 
was  looked  at,  and  the  first 
impression  made  was  that 
it  indicated  the  position  of 
the  stomach.  By  means, 
to  be  presently  described,  the  position  of  the  stomach  was 
determined  to  be  as  shown  in  the  dotted  line ;  therefore 
the  peristaltic  movement  was  not  present  in  the  stomach 
but  in  the  transverse  colon.  It  is  necessary  to  mention 
here  that  the  transverse  colon  always  descends  with  the 
stomach,  and  is  to  be  found  along  its  inferior  border  no 
matter  how  low  that  border  may  be. 

The  converse  is  by  no  means  always  the  case,  for  the 
stomach  may  be  normal  in  position,  while  the  transverse 
colon  forms  a  great  downward  loop  with  its  hepatic  and 
splenic  ends  attached  in  their  normal  positions  in  right  and 
left  hypochondria. 

In  the  preceding  method  of  examination,  and  in  the 
following  procedures,  it  is  necessary  to  be  on  the  right-hand 
side  of  the  bed  or  couch  on  which  the  patient  is  lying. 


SUCCUSSION  71 

Palpation  and  Splashing. — By  palpation  alone  the  more 
or  less  rounded  form  of  the  stomach  can  sometimes  be 
felt  as  it  contracts  on  its  contents  ;  but  we  do  not  reckon 
on  this  as  a  phenomenon  to  be  depended  on  to  help  our 
examination.  The  production  of  splashing  is,  on  the  other 
hand,  of  great  value.  It  is  elicited  by  tapping  with  the  points 
of  two  fingers,  or  by  abrupt  but  gentle  pressure  of  the  four 
fingers  and  equally  sudden  removal  of  the  pressure.  The 
production  of  the  sound  depends  upon  the  stomach  being 
in  contact  with  the  parietes  and  containing  fluid  and  air. 
It  can  be  elicited  in  all  cases  of  dilatation  with  sagging  of  the 
lower  border  and  in  ptosis.  The  area  over  which  splashing 
is  elicited  can  be  marked  with  a  pencil.  The  boundaries 
which  can  be  defined  by  this  method  are  the  lower  border 
or  great  curve,  the  lesser  curve  in  the  middle  line,  and  the 
right  border,  which  may  reach  to  the  costal  margin.  If 
the  phenomena  are  not  obtained  because  there  is  not  sufficient 
fluid  in  the  stomach,  it  is  obtained  by  giving  a  tumblerful 
or  more  of  hot  water.  This  method  is  by  itself  of  great 
service,  but  the  physical  conditions  present  can  be  further 
utilized  by  the  two  additional  methods  of  succussion  and  of 
auscultation-succussion. 

Succussion. — When  fluid  and  air  are  present  in  an 
enlarged  stomach  a  succussion  wave  can  be  felt  when  the 
abdomen  is  properly  manipulated.  To  do  this  the  left  hand 
is  placed  flat  over  the  lateral  aspect  of  the  lower  ribs  on  the 
left  side  while  the  right  is  placed  across  the  epigastrium. 
The  left  and  right  hands  are  alternately  pressed  with  a  jerk 
inwards,  in  such  a  way  as  to  produce  a  movement  in  the 
stomach  contents,  and,  when  this  is  done  efficiently  and  with 
due  intelligence,  the  wave  is  felt  to  impinge  upon  the  hand. 
In  many  cases  the  precise  position  of  the  lower  border,  and 
of  the  right  limit  (which  for  convenience  we  call  the  right 
border) ,  of  the  organ  can  be  thus  determined  and  marked  ; 
the  position  of  the  lesser  curve  can  also  be  determined  in 
this  way,  and  in  many  cases  even  the  position  of  the  fundus 
can  be  confirmed  by  making  the  splash  travel  upwards 
by  the  hand  placed  over  the  body  of  the  viscus,  while  the 


72  THE   STOMACH 

other  is  over  the  fundus.  The  Hnes  which  succussion  gives 
are  absolutely  correct,  but  a  certain  amount  of  judgment  has 
to  be  exercised  when  the  method  is  used  :  the  position  of 
the  hands  has  to  vary  with  the  position  of  the  stomach  ; 
sometimes  one  kind  of  movement,  at  other  times  another 
kind  of  movement  will  be  found  the  best  for  producing  the 
succussion  wave  in  different  stomachs,  li  the  contents 
are  not  fluid  enough  a  cup  of  hot  water  can  be  added  to 
them.  If  to  judgment  and  common  sense  a  measure 
of  patience  is  added,  the  succussion  wave  can  always 
be  got. 

Auscultation-Succussion. — This  method  of  examination  is 
very  interesting.  It  consists  in  listening  with  the  stetho- 
scope over  the  stomach  when  its  contents  are  made  to 
splash.  It  is  desirable  to  use  a  binaural  stethoscope  for 
this  purpose  :  it  is  applied  over  the  stomach  by  one  hand, 
while  with  the  other  the  splash  is  caused,  or  the  splash  may 
be  set  up  by  alternating  the  movement  of  the  free  hand 
with  the  movement  of  the  hand  holding  the  stethoscope  in 
position.  The  splash,  however  faint  it  may  be,  is  readily 
heard  through  the  stethoscope,  and,  if  the  stethoscope  be 
moved  from  one  point  to  another,  it  will  be  found  that  the 
splash  has  a  loudness  and  a  tone  when  the  stethoscope  is  over 
the  stomach  quite  distinct  from  the  sound  heard  when  the 
stethoscope  is  no  longer  over  it.  This  method  of  examination 
is  sometimes  very  helpful  where  succussion  alone  is  not 
satisfactory,  or  where  the  splash  is  not  felt  well.  I  have 
frequently  been  able  in  this  way  to  determine  the  right 
border  of  the  stomach  when  without  it  I  might  have  been 
in  doubt.  The  upper  limit  of  the  fundus  can  also  be  thus 
determined  with  accuracy.  The  variety  of  tone  produced 
by  the  sound  of  the  splash  in  the  air-containing  fundus 
will  interest  any  one  who  is  attracted  by  auscultatory 
phenomena. 

By  these  various  methods  the  position  in  the  recumbent 
position  of  the  enlarged  stomach  can  be  accurately  deter- 
mined. The  common  idea  that  the  splashing  referred  to 
may  be  in  the  colon  has  to  be  entirely  abandoned.     It  is 


ABSENCE  OF  PHYSICAL  SIGNS  OF  DILATATION    73 

one  of  the  relics  of  the  days  of  ignorance  to  which  currency 
ought  no  longer  to  be  given. 

The  Right  Border.— The  term  "  right  border,"  as  ap- 
phed  to  the  stomach,  is  a  chnical  term  used  to  define  the 
right  hmit  of  the  stomach  as  it  can  be  determined  by  the 
methods  which  have  been  described.  An  explanation  of 
the  term  is  necessary  to  enable  its  significance  to  be  under- 
stood, and  it  is  as  foUows.  It  was  repeatedly  noted  at 
operations  on  such  cases  as  have  been  described,  that  the 
dilated  organ  was  carried  or  thrown  to  the  right  while  the 
pylorus  remained  in  its  normal  position  ;  the  result  was  that, 
when  the  abdomen  was  opened,  this  portion  of  the  stomach, 
had  to  be  drawn  aside  or  out  of  the  abdominal  wound  in 
order  to  expose  the  pylorus.  It  is  this  folded-over  portion 
which  gives  the  "  right  border."  The  fact  that  such  a 
definite  border  can  be  clinically  determined  in  the  recumbent 
position  becomes  evidence  of  great  dilatation  and  sagging  ; 
and  it  will  be  shown  that  the  determination  of  the  position 
of  this  border  is  a  great  help  in  diagnosis,  and  in  determining 
whether  surgical  interposition  is  necessary. 


The  Absence  of  Physical  Signs  of  General 
Dilatation 

The  phenomena  obtained  by  the  foregoing  method  of 
examination  are  absolute  proof  of  general  dilatation  if  the 
examination  is  made  when  the  contents  of  the  stomach 
are  in  sufficient  quantity  to  make  it  reasonable  to  expect 
the  phenomena.  The  best  time  to  make  the  examination 
is  from  one  to  two  or  three  hours  after  a  meal,  and,  as  already 
stated,  it  often  makes  the  phenomena  clearer  if  the  patient 
drinks  a  tumblerful  of  hot  water.  The  reason  of  again 
emphasizing  this  is  that,  if  the  phenomena  canjiot  he  obtained, 
or  are  confined  to  the  fundal  part  of  the  stomach,  it  means 
that  there  is  no  dilatation  of  the  pyloric  half  and  no  sagging 
of  the  lower  border  of  the  viscus  ;  and  it  is  this  general 
enlargement  or  dilatation  which  is  of  special  and  particular 
clinical  significance,  as  will  be  seen  later. 


74  THE  STOMACH 

Explanation  of  Absence  of  Suceussion  Wave. — Before 
leaving  this  subject  it  is  necessary  to  refer  to  cases 
of  dilatation  in  which  the  splash  cannot  be  elicited  right 
across  the  abdomen  from  the  left  hypochondrium  to 
the  right  of  the  middle  line,  by  the  method  described.  In 
a  considerable  number  of  cases  of  much  enlargement  it 
will  be  found  that  a  splash  can  be  obtained  to  the  left  of 
the  middle  line  by  smartly  pressing  with  the  fingers,  but  no 
wave  can  be  produced  across  the  middle  line  ;  while  by 
again  smartly  pressing  with  the  fingers  between  the  middle 
line  and  the  right  costal  margin,  a  separate  splash  or  gurghng 
or  squelching  can  be  obtained.  The  explanation  of  this  is  that 
the  stomach  is  not  full,  and,  as  the  patient  is  lying  fiat  on 
his  back,  the  portion  of  viscus  in  front  of  the  spine  flattens 
itself  against  the  spine  and  the  stomach  is  thereby  divided 
into  two  compartments.  It  thus  becomes  a  physical 
impossibility  for  the  suceussion  wave  to  pass  from  the  one 
side  to  the  other.  This  explanation  can  be  confirmed  by 
X-ray  examination  with  bismuth.  Illustrations  will  be 
found  in  Figs.  4  and  6:  in  them  the  bismuth  is  shown  in 
two  compartments,  one  the  larger  to  the  left  of  the  vertebrae, 
the  other  the  smaller  to  the  right.  The  appearance  of  two 
compartments  is,  of  course,  lost  when  the  patient  is  examined 
in  the  upright  position.  When  there  is  considerable  air 
present  it  occupies  this  central  position  in  the  recumbent 
position,  so  that  a  tympanitic  note  is  present  over  the  spine, 
while  to  left  and  right  of  it  splash  or  gurgle  is  elicited. 

X-RAY  Examination 

The  clinician  by  the  methods  described  can  only  deter- 
mine the  position  of  the  stomach  in  the  recumbent  position  ; 
but  he  can  determine  it  as  accurately  as  X-ray  examination 
does.  X-ray  examination  of  the  stomach  after  a  bismuth 
meal,  however,  not  only  gives  its  position  in  recumbency,  but 
also  in  the  erect  position.  The  great  difference  in  the  picture 
of  these  two  positions  is  to  me  one  of  the  most  interesting 
and  important  revelations  made  by  radiography.     I  never 


Fig.  4. — Showing  stomach,  in  recumbent  position,  with 
bismuth  to  right  and  left  of  the  spine,  and  the  air- 
space at  A.     Black  rectangle,  umbilicus. 

[To  face  page  74. 


Ck.v 


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spii 

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cus. 

fc  ^  ^  s 

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[To  face  page  75. 


X-RAY    EXAMINATION  75 

forget  the  first  time  I  liandled  the  abdomen  with  the  patient 
on  a  couch  and  the  tube  underneath  it.  On  palpating  the 
Ciecum  the  bismuth-containing  stomach  and  intestine 
moved  as  if  floating  in  fluid.  The  accompanying  figures 
show  the  remarkable  difterence  in  the  position  of  the  stomach 
in  these  two  postures.  Fig.  5  is  taken  erect,  the  lesser  curve 
being  much  dropped,  while  the  greater  curve  is  much  below 

O  Q 


Fig.  7. — Tracing  of  stomach,  same  as  Fig.  6. 

the  iliac  crests.  Fig.  6  is  taken  recumbent  and  it  is  seen 
that  the  greater  curve  is  midway  between  the  umbilicus 
and  the  xiphisternum,  while  the  lesser  curve  is  up  under  the 
ribs.  Fig.  7  is  my  tracing  taken  in  the  recumbent  position, 
and  it  is  to  be  noted  how  closely  it  corresponds  to  the  X-ray 
picture  taken  recumbent.  Now  the  change  here  portrayed 
can  be  so  certainl}'-  reckoned  on  that  from  the  tracing  obtained 
in  the  recumbent  position  one  can  predict  what  the  X-ray 
picture  will  show  when  taken  erect.  In  the  earlier  experiences 
of  radiography  the  picture  in  the  upright  position  so  misled 
the  surgeon  that  X-ray  examination  for  this  purpose  became 
temporarily  discredited.  It  was  at  that  time,  or  before  it, 
that  I  had  worked  out  the  methods  described  of  determining 
the  position  of  the  stomach  with  the  patient  recumbent, 


76  THE   STOMACH 

and  my  tracing  gave  the  position  of  the  stomach  as  the 
surgeon  found  it  when  he  opened  the  abdomen.  The  throwing 
over  of  the  dilated  stomach  to  the  right  so  as  to  cover 
pylorus  and  duodenum,  and  thereby  to  give  a  right  border 
which  becomes  a  guide  to  the  clinician,  is  a  fact  of  which 
there  is  no  doubt.  Professor  Caird  informs  me  that  he  has 
seen  this  prevent  leakage  from  a  duodenal  perforation. 


The  Right  Border  in  the  Recumbent  Position  as  a 
Guide  to  Pyloric  or  Duodenal  Lesion 

Having  thus  shown  that  the  size  and  position  of  the 
stomach  can  be  determined  by  ordinary  methods  of  physical 
examination,  emphasis  may  be  laid  on  certain  conclusions 
which  follow  upon  the  observations.  In  stomachs  where 
the  fundus  only  is  dilated  the  right  border  does  not  extend 
to  the  right  of  the  middle  line.  When  the  whole  organ  is 
dilated  the  right  border  is  found  to  the  right  of  the  middle 
line  in  proportion  to  the  degree  of  dilatation.  When  there 
is  dilatation  and  ptosis  the  right  border  is  midway  between 
the  middle  line  and  the  right  costal  margin,  or  right  over  to 
the  costal  margin.  From  the  position  of  the  right  border 
the  degree  of  dilatation  and  of  ptosis  may  be  estimated ; 
and  if  this  be  watched  hour  by  hour  after  a  meal  it  can  be 
determined  how  long  the  stomach  takes  to  empty.  This 
observation  is  of  great  value  in  checking  and  correcting 
an  opinion  based  on  X-ray  observations  made  after  a 
bismuth  meal.  It  will  be  found  that  the  bismuth  meal  is 
got  rid  of  in  much  shorter  time  than  the  ordinary  meal  of 
mixed  foods.  By  watching  thus  it  can  be  shown  that  the 
stomach  contents  are  slowly  got  rid  of,  that,  in  short,  there 
is  undue  retention.  When  this  is  found  it  strongly  suggests 
the  possibility,  and  indeed  probability,  of  pyloric  difficulty 
being  present,  due  to  hyperacidity  being  associated  with 
duodenal  ulcer,  pyloric  ulcer  or  scar,  or  congenital  narrow- 
ing. If  undue  retention  can  be  shown  to  persist,  and  is 
causing   discomfort,    it    commonly   means   that   a   gastro- 


PYLORIC   OR   DUODENAL   LESION  ^^ 

enterostomy  is  required  for  complete  relief,  and  relief  is 
complete  only  when  the  new  opening  prevents  the  retention 
of  a  residmmi  of  the  food  which  has  been  taken. 

This  subject  is  referred  to  more  fully  in  the  introductory 
chapter  dealing  with  the  pylorus  and  duodenum. 


CHAPTER  VIII 

DILATATION   OF  THE   STOMACH — TWO   TYPES 

Dilatation  of  the  stomach  is  not  a  primary  disorder.  It 
is  not  a  clinical  entity  and  ought  never  to  be  regarded  as  a 
disease  by  itself.  It  is,  however,  a  sign  or  evidence  of  large 
value  in  the  consideration  of  gastric  disorder  and  disease. 
Its  recognition  is  often  the  first  step  towards  a  diagnosis  ; 
and  too  much  stress  cannot  be  laid  on  the  importance  of 
being  able  to  recognize  the  existence  of  the  condition. 
The  method  of  investigation  has  been  described  in  the 
preceding  chapter.  When  dilatation  is  recognized  the 
next  question  which  requires  an  answer  is  "  what  has  led 
to  it  ?  "  It  is  only  when  this  question  is  answered  that 
the  line  which  treatment  ought  to  foUow  is  made  plain. 

Under  the  name  of  dilated  stomach  there  has  been  much 
confusion  of  thought,  due  apparently  to  its  being  regarded 
as  a  specific  and  definite  malady. 

There  are  at  least  two  conditions  to  which  the  name  is 
applied.  The  first  and  commoner  form  of  dilatation  is 
characterized  by  enlargement  of  the  fundus  of  the  viscus 
with  extension  of  the  great  curve  upwards  and  to  the  left, 
and  a  corresponding  increase  in  the  antero-posterior  diameter 
of  the  organ.  This  type  of  dilatation  is  met  with  in  big 
feeders,  and  may  sometimes  be  regarded  merely  as  a  big 
stomach.  It  may  or  may  not  be  associated  with  symptoms 
calling  for  medical  treatment.  The  other  form  of  dilata- 
tion is  that  in  which  the  inferior  border  of  the  stomach 
has  fallen  below  the  level  of  the  pyloric  outlet,  when  at  the 
same  time  there  is  enlargement  of  the  cavity  and  atony, 
although    not    immobilit}^,    of    the    muscular    coat.     This 

78 


DILATATION   OF   THE  STOMACH  79 

form  can  be  conveniently  called  ptosis  of  the  inferior  border  ; 
this  means  that  there  is  sagging  of  the  great  curve,  without 
ptosis  of  the  viscus  as  a  whole. 

In  this  connection  let  me  remind  you  that  the  position  of 
the  pyloric  outlet  moves  somewhat  with  the  position  of 
the  stomach  ;  it  moves  somewhat  to  the  right  and  slightly 
downwards,  but  it  does  not  descend  in  proportion  to  the 
degree  of  ptosis  of  the  inferior  border.  One  result  is  that, 
when  this  form  of  ptosis  occurs,  the  pyloric  outlet  is  con-, 
siderably  above  the  level  of  the  lower  border ;  and,  as 
ptosis  is  alwaj^s  associated  with  considerable  muscular  atony, 
the  stomach  takes  long  to  empty  itself,  and  in  many  cases 
may  never  empty  itself  completely.  This  condition  of 
things  is  prone  to  occur  in  hyperchlorhydria  ;  it  is  the  cause 
of  much  discomfort ;  it  tends  to  increase,  and  the  symptoms 
to  become  more  severe.  When  recognized  early,  the  checking 
of  the  hyperchlorhydria  is  followed  by  restoration  of  tone, 
and  by  recovery  from  the  ptosis.  With  the  recurrence 
of  the  hyperchlorhydria  the  ptosis,  however,  recurs  also, 
with  its  accompanying  miseries.  In  a  patient  seen  from 
time  to  time  during  the  last  three  years  there  have  been 
several  outbursts  of  hyperchlorhydria  with  accompanying 
ptosis,  and  a  prominent  feature  in  the  case  has  been  that 
with  the  recurrence  of  the  hyperchlorhydria  extraordinary 
quantities  of  fluid  were  poured  out  into  the  stomach.  He 
has  been  entirely  without  symptoms  for  as  long  a  period 
as  eight  months.  When  he  is  free  of  gastric  symptoms 
there  is  a  relaxation  of  dietetic  rules  ;  he  is  a  busy  and  a 
hard-working  man,  who  will  travel  to  London  one  night, 
transact  business  during  the  day,  dine,  and  return  to  Edin- 
burgh b}^  the  night  mail,  with  the  result  that  symptoms 
may  return.  He  can  manage  himself  so  well  that  he  often 
cuts  the  attack  short ;  but,  if  he  does  not  succeed,  I  see 
him  again,  and  he  has  been  warned  that  these  recurring 
attacks  may  leave  the  stomach  in  such  a  condition  that  he 
will  ultimately  require  a  gastro-enterostomy.  In  this  case 
it  is  -probable  that  there  are  pyloric  or  duodenal  adhesions 
intensifying  the  mechanical  difficulty,  by  keeping  the  pyloric 


8o  •  THE  STOMACH 

outlet  in  a  fixed  position,  and  that  consequently  there 
is  no  movement  of  accommodation  on  its  part.  He  is  not 
desirous  of  having  an  operation,  as  he  has  a  friend  who, 
in  spite  of  a  gastro-enterostomy  having  been  performed, 
has  still  to  exercise  caution  in  his  dietetic  habits. 

This  leads  me  to  point  out  that  this  condition  of  ptosis 
of  the  lower  border  is  more  intractable,  not  only  where 
there  are  adhesions  or  narrowing  from  old  healed  ulcer, 
but  also  in  cases  where  there  is  congenital  narrowing  of 
the  pyloric  outlet  or  where  the  pylorus  is  abnormally 
high  in  position.  I  saw  a  case  of  the  last  description  in  a 
medical  man,  who  had  suffered  so  long  and  so  severely 
from  digestive  miseries  that  I  thought  it  quite  likely  that 
his  pylorus,  which  I  determined  was  high  in  position, 
might  be  fixed  in  its  high  position  by  old  adhesions,  and 
yet  at  the  operation  it  was  shown  that  none  existed.  A 
gastro-enterostomy  was,  however,  done,  with  marked 
benefit.  In  this  patient,  from  the  relation  of  the  pylorus  to 
the  lower  border  of  the  stomach,  it  was  clear  that  the 
stomach  could  not  empty  itself  properly,  and  the  new 
opening  afforded  a  channel  which  enabled  it  to  do  so. 
Another  patient,  whom  I  saw  some  months  ago,  had  a 
like  sagging  of  the  lower  border,  which  had  not  yielded 
to  treatment,  and  who  also  had  symptoms  indicating 
pyloric  difficulty  from  previous  duodenal  lesion.  I  at 
once  recommended  gastro-enterostomy.  At  the  operation 
old  duodenal  lesion  with  adhesions  was  found  of  such  a 
kind  that  would  have  made  an  attempt  at  medical  treat- 
ment ridiculous.  She  also  did  well,  and  was  much  benefited 
by  the  gastro-enterostomy.  This  patient  had  been  diagnosed 
a  year  before  as  a  neurasthenic  ;  but  blunders  of  this  kind 
are  no  more  to  be  taken  as  the  standard  of  the  physician's 
work  than  the  blunder  of  opening  the  abdomen  unneces- 
sarily is  to  be  taken  as  the  standard  of  the  surgeon's  capacity. 
The  aim  of  the  physician  ought  ever  to  be  to  reduce 
the  margin  of  error  in  internal  diagnosis  to  vanishing  pro- 
portions. 

Further  illustrations  of  gastric  dilatation  will  be  given 


DILATATION  OF  THE   STOMACH  8i 

as  the  lesions  which  determine  the  dilatation  are  considered. 
The  subject  has  been  meanwhile  dealt  with  in  this  way  to 
emphasize  its  great  importance  as  a  demonstrable  anatomical 
change  which  has  been  produced  in  the  viscus  ;  and  that 
the  presence  of  the  condition  can  be  determined  without 
the  assistance  of  X-ray  examination. 


CHAPTER   IX 

GASTROPTOSIS,    OR   DISLOCATION   OF  THE   STOMACH 

Definition. — Gastroptosis  is  the  modern  designation  of 
what  was  formerly  called  "  dislocation  of  the  stomach." 
It  is  a  falling  down  or  prolapse  of  the  organ  as  a  whole,  so 
that  its  body  occupies  a  lower  position  in  the  abdominal 
cavity  than  it  does  normally.  As  part  of  a  visceroptosis 
it  is  dealt  with  in  Chapter  XVI. 

Anatomical  Considerations. — The  size  of  the  stomach 
varies  within  very  wide  limits,  even  in  what  is  commonly 
regarded  as  normal  conditions.  After  starvation  or  after  a 
period  of  very  spare  diet  small  in  bulk,  the  viscus  is  as  small, 
or  even  smaller,  than  the  soda-water  bottle  with  the  egg- 
shaped  end.  In  many  pictorial  representations  it  is  shown 
as  much  larger  than  this  by  several  times,  indeed,  many 
of  these  representations  have  evidently  been  taken  from 
bodies  in  which  the  organ  was  dilated.  When  dilated  its 
shape  and  proportions  are  greatly  altered,  and  also  the 
direction  of  its  main  axis.  Full  consideration  has  already 
been  given  to  degrees  of  dilatation,  here  it  is  only  necessary 
to  recall  some  facts  which  bear  upon  gastroptosis.  It  is 
in  the  first  place  to  be  remembered  that  the  cardiac  orifice 
of  the  stomach  is  practically  a  fixed  point,  and  that  from  it 
the  lesser  curvature  of  the  viscus  runs  downwards  and  to 
the  right  to  the  pyloric  orifice.  This  lesser  curvature  is 
well  under  cover  of  the  liver  in  the  epigastrium  in  the  normal 
state.  It  is  held  in  position  with  considerable  firmness 
by  means  of  ligaments  ;  but  also  probably  by  a  certain 
negative  pressure,  as  the  liver  is  held  in  contact  with  the 

82 


GASTROPTOSIS  83 

arch  of  the  diaphragm.  The  greater  curvature  is  totally 
different ;  it  varies  in  position  with  the  size  and  the  degree 
of  dilatation  of  the  viscus.  The  greater  curvature  may 
reach  to  a  line  far  below  its  normal  limits  without  dislocation 
of  the  viscus  being  present,  without  there  being  any  change 
in  position  more  than  follows  necessarily  upon  the  enlarge- 
ment of  dilatation.  Gastroptosis  occurs  when  the  lesser 
curvature  fails  to  maintain  its  position.  When  the  lesser 
curvature  begins  to  sag  gastroptosis  has  begun.  This 
sagging  of  the  lesser  curvature  is  due  to  dragging  upon  it 
by  the  stomach  and  its  contents.  It  is  preceded  b}^  stomach 
dilatation,  with  atony  and  prolonged  retention  of  food. 
The  result  is  due  to  the  simple  physical  factors  weight  and 
strain.  The  viscus  may  be  regarded  as  a  bag  suspended  in 
the  abdominal  cavity,  one  end  of  which,  the  oesophageal 
end,  is  firmly  attached,  while  the  other  end,  the  pyloric 
end,  has  a  much  less  stable  attachment.  Along  the  lesser 
curvature  there  is  a  delicate  fold  of  peritoneum,  which  is 
attached  above  to  the  liver,  is  known  as  the  gastro -hepatic 
omentum,  and  is  presumably  a  factor  of  considerable  value 
in  keeping  the  organ  in  position.  The  gastro-hepatic 
omentum  cannot,  however,  be  regarded  as  likely  to  success- 
fully sustain  any  prolonged  increase  of  strain  put  upon  it. 
It  is  quite  certain,  moreover,  that  there  must  be  greatly 
increased  strain  when  the  hag  becomes  atonically  relaxed 
and  its  contents  accumulate.  There  is  no  doubt  that  the 
sequence  of  events  is  that  the  lesser  curvature  sags,  stretches, 
and  is  displaced  downwards.  This  is  the  starting-point 
of  gastroptosis.  So  long  as  this  has  not  taken  place  the 
stomach  is  only  dilated,  no  matter  how  great  the  dilatation 
may  be.  Gastroptosis  is,  however,  very  liable  to  occur 
when  there  is  marked  dilatation,  with  prolonged  retention 
of  stomach  contents.  It  is  indeed,  the  strain  of  the  weight 
of  the  stomach  which  makes  the  gastro-hepatic  ligament  to 
yield.  While  the  essential  factor  is  what  has  been  indicated, 
there  is  a  predisposing  factor  which  ought  not  to  pass 
unnoticed  :  that  is,  the  condition  of  the  abdominal  wall 
and  of  the  intestine.     When  the  muscles  of  the  abdominal 


84  THE   STOMACH 

wall  are  firm,  and  the  tone  of  the  muscular  coat  of  the  intes- 
tine good,  the  firmness  of  the  packing  within  the  abdominal 
cavity  forms  a  strong  support  to  the  stomach,  preventing 
its  dislocation.  The  converse  must  be  equally  true,  and  it 
is  mainly,  if  not  entirely,  in  lax  abdomens  that  gastroptosis 
commonly  occurs.  There  is  still  another  support  which, 
so  far  as  the  writer  knows,  has  not  been  hitherto  noted, 
namely,  the  transverse  colon.  This  part  of  the  colon  is 
in  contact  with  the  greater  curvature  of  the  stomach  and 
moves  with  it,  descending  and  retracting  as  it  descends  and 
ascends.  While  this  is  true  of  the  transverse  colon,  it  is 
not  applicable  to  its  ends,  known  to  anatomists  as  the 
hepatic  and  splenic  flexures.  These  ends  are  firmly  united 
to  the  parietes  so  firmly  that  they  may  retain  their  position 
in  great  measure  even  in  extreme  cases  of  gastroptosis. 
Owing  to  this  fixedness  of  the  flexures,  the  transverse  colon 
must  therefore  provide  an  additional,  and  a  considerable 
measure  of  support  to  the  stomach. 

When,  notwithstanding  these  various  checks  or  hin- 
drances, gastroptosis  begins,  it  readily,  and  in  some  cases 
rapidly,  increases.  The  fact  of  its  starting  implies  defect 
in  the  various  factors  which  have  been  mentioned  ;  and, 
if  the  condition  which  starts  it  is  not  recovered  from,  but 
persists,  the  inevitable  sequence  is  a  steadily  progressive 
degree  of  displacement.  As  the  displacement  has  as  its 
determining  cause  dilatation  or  sagging,  the  persistence 
of  the  dilatation  not  only  continues  to  operate  in  increasing 
the  displacement  but  it  also  leads  to  increase  of  the  dilata- 
tion itself.     The  two  conditions  thus  advance  hand  in  hand. 

The  degree  of  displacement  is  measured  by  the  position 
of  both  the  lesser  and  the  greater  curvatures.  The  former, 
that  is  the  lesser  curvature,  may  reach  at  its  most  dependent 
part  to  a  point  as  low  as  from  one  to  two  inches  below  the 
level  of  the  umbilicus.  I  have  never  seen  it  lower  than 
this.  In  more  moderate  degrees  it  reaches  to  a  point  one- 
third  or  one-half  of  the  way  between  the  ensiform  and  the 
umbilicus.  The  greater  curvature  at  its  most  dependent 
part  reaches  to   a  correspondingly  low  position.     I  have 


Fig.  8.- — Gastroptosis.  L,  liver;  S,  stomach;  P,  pylorus;  Dr,  first  part  of 
duodenum;  D3,  third  part  of  duodenum ;  PA.  pancreas;  C,  colon;  XX, 
anterior  ilica  spine  ;   X,  umbilicus. 

[To  face  page  85. 


GASTROPTOSIS  85 

seen  it  reach  to  the  pubes  and  to  an  inch  or  two  short  of 
that  level.  In  such  extreme  cases  the  upper  part  of  the 
stomach  is  sometimes  stretched  so  as  to  form  a  long  tube- 
like structure,  the  left  edge  being  formed  by  part  of  the 
greater  curvature,  while  the  right  edge  is  formed  by  part 
of  the  lesser  curvature — these  edges  descend  more  or  less 
parallel  with  each  other  until  they  respectively  reach  their 
lowest  points  and  then  turn  upwards  in  such  a  way  as  to 
convert  the  organ  into  a  large  U-shaped  tube  with  a  short 
right-handed  limb.  In  other  cases,  along  with  great  ptosis 
the  cardiac  end  may  be  greatly  dilated  as  is  shown  in  Fig.  8. 
In  extreme  cases  the  pylorus  shares  in  the  dislocation  to  a 
very  marked  extent.  In  the  accompanying  sketch  it 
is  seen  almost  at  the  level  of  the  umbilicus,  and  in  the  same 
sketch  it  will  be  found  that  the  first  part  of  the  duodenum 
has  been  so  dragged  upon  and  displaced  that  it  forms  the 
upper  part  of  the  limb  of  the  U-tube  to  the  left.of  the  observer. 

As  the  stomach  descends  it  carries  with  it  the  transverse 
colon  while  the  small  intestines  also  are  pushed  downwards. 
So  great  may  the  displacement  be  that  the  small  intestines 
are  packed  into  a  clump  in  the  true  pelvis.  The  transverse 
colon  is  stretched  to  an  extraordinary  degree  and  in  the 
stretching  becomes  extremely  attenuated.  So  thin  does  it 
become  that  it  is  rendered  transparent  so  that  any  scybala 
lying  in  it  are  plainly  visible.  The  downward  displacement 
of  the  stomach  exposes  part  of  the  pancreas,  while  in  the 
case  from  which  the  accompanying  sketch  was  made  the 
third  part  of  the  duodenum  was  also  exposed  immediate^ 
below  the  pancreas. 

In  gastroptosis  there  is,  as  stated,  great  displacement 
of  the  small  intestine  and  of  the  transverse  part  of  the 
colon,  due  entirely  to  the  weight  and  pressure  of  the  dilated 
organ  stretching  the  structures  which  act  as  moorings. 
So  great  is  the  displacement  that  it  is  amazing  the  victims 
of  the  condition  can  go  on  as  long  as  they  do.  The  purely 
physical  difficulties  look  as  if  they  were  unsurmountable. 
Reference  to  Fig.  8  will  illustrate  what  is  here  indicated. 
In  the  upright  position  of  the  trunk  the  gastric  contents  fall 


86  THE  STOMACH 

by  gravity  to  the  dependent  part  of  the  U-tube,  and  nothing 
can  possibly  pass  into  the  duodenum  unless  the  tube  be 
filled  well  up  towards  the  cardiac  end,  which  would  mean 
quarts  of  stomach  contents.  Passage  into  the  duodenum  can 
only  take  place  when  the  body  is  recumbent,  either  on  the 
back  or  inclined  to  the  right  side.  Turning  to  the  left  side 
throws  the  stomach  contents  into  the  left  limb  of  the  U 
and  away  from  the  pylorus.  In  some  of  the  cases  I  have 
seen  the  passage  of  food  from  the  stomach  must  for  years 
have  been  confined  in  the  main  to  the  hours  of  night  which 
were  the  hours  set  aside  for  sleep. 

Symptoms. — The  symptoms  necessarily  vary  in  intensity, 
but  in  view  of  the  great  displacement  of  the  gastro-intestinal 
tract  the  marvel  is  that  they  are  not  much  worse  than  they 
are.  There  are  symptoms  of  indigestion  and  of  dyspepsia  ; 
the  sense  of  a  load  in  the  abdomen,  or  a  feeling  of  dragging  ; 
flatulence,  eructations,  pain.  The  symptoms  are  intensified 
some  time  after  taking  food.  There  may  be  nausea  and 
vomiting  from  time  to  time.  A  sense  of  weariness,  of 
languor,  and  of  inability  for  physical  activity,  and  in  women 
for  domestic  duties,  is  present.  When  the  condition  has 
become  extreme  and  has  lasted  long,  there  ensues  loss  of 
appetite,  or  even  repugnance  to  food  ;  considerable  thirst ; 
vomiting,  coming  on  on  slight  provocation ;  progressive 
asthenia,  extreme  emaciation,  and  death. 

Physical  Examination. — On  examining  the  digestive 
system  the  tongue  is  found  to  be  more  or  less  furred  or 
coated  and  moist.  There  is  constipation,  but  the  bowels 
can  be  made  to  move  by  means  of  purgatives.  The  diagnosis 
rests  upon  the  physical  examination  of  the  abdomen.  On 
inspection,  in  extreme  cases  the  part  of  the  abdomen  below 
the  level  of  the  umbilicus  is  prominent,  as  compared  with 
the  part  above  ;  but  this  fullness  may  not  reach  to  the 
pubes.  In  less  extreme  cases  the  prominent  part  of  the 
abdomen  is  higher  than  this.  It  corresponds  with  the 
position  of  the  displaced  organ.  The  prominence  is  usually 
to  be  noted  even  with  the  patient  lying  on  the  back  ;  but 
it  is  more  pronounced  when  standing  or  sitting.     In  the 


GASTROPTOSIS  87 

icciimbent  position  the  contractions  of  the  viscus  can 
sometimes  be  noted.  The  most  important  evidence  is 
obtained  by  palpation,  and  by  this  means  the  diagnosis 
can  be  made  with  certainty.  Using  both  hands  the  splash 
or  succussion  sound  and  wave  of  the  stomach  contents  is 
readily  produced,  and  as  the  viscus  is  never  empty,  but 
always  contains  more  or  less  fluid  or  semifluid  contents  and 
air,  the  sign  can  be  elicited  almost  at  any  time.  The 
succussion  wave  can  be  made  to  indicate  with  absolute 
precision  the  inferior  or  most  dependent  part  of  the  organ, 
and  can  also  be  made  to  reveal  with  equal  precision  the 
position  of  the  lesser  curvature.  When  these  two  points 
are  determined  it  is  not  difficult  to  determine  the  position 
of  the  rest  of  the  organ.  Percussion  will  determine  the 
boundaries  of  the  organ  at  the  fundus.  When  there  is 
not  sufficient  air  to  distend  this  part  it  is  usually  little  more 
than  a  narrow  tube,  the  position  of  which  cannot  be  demon- 
strated either  by  palpation  or  percussion,  but  can  be  correctly 
inferred  by  determining  the  position  of  the  lower  part  of 
the  organ,  and  bearing  in  mind  that  the  cardiac  opening 
remains  a  fixed  point.  If  the  patient  be  turned  from  the 
supine  position  to  the  left  side,  the  stomach  contents  fall  over 
to  that  side,  causing  a  marked  projection,  while  the  position 
of  the  succussion  wave  is  also  changed.  In  cases  of  this 
extreme  degree  of  displacement  care  has  to  be  exercised 
that  the  position  of  the  stomach  is  not  entirely  overlooked. 
This  sometimes  happens  by  the  examination  being  confined 
to  the  upper  half  of  the  abdomen,  particularly  over  the 
normal  gastric  region,  when,  of  course,  the  negative  results 
obtained  will  lead  to  a  totally  erroneous  opinion  of  the 
condition  present. 

Congenital  Pyloric  Stenosis  as  a  Cause  of 
gastroptosis. 

Not  only  may  gastroptosis  be  due  to  prolonged  reten- 
tion of  food  in  the  stomach  from  acquired  lesion  at  or 
near  the  pylorus,  it  may  also  be  the  result  of  congenital 
stenosis  of  the  pylorus.     When  this  stenosis  exists  it  leads 


88  THE  STOMACH 

to  conditions  which  are  highly  favourable  to  the  production 
of  ptosis.  The  stenosis  leads  to  a  slow  escape  of  the  stomach 
contents  into  the  duodenum,  even  with  the  most  perfect 
gastric  titration  and  digestion,  and  whenever  there  is  delay 
of  this  kind  the  stomach  wall  is  liable  to  become  exhausted. 
Exhaustion  leads  to  dilatation  and  to  still  more  prolonged 
retention  of  contents  and  also /favours  the  establishment  of 
catarrh.  If  lumps  of  food  such  as  potato  and  bread  crust  are 
swallowed  they  lead  to  much  difficulty,  for  it  is  impossible  for 
such  masses  to  pass  through  a  congenitally  constricted  pylorus, 
so  here  there  is  an  additional  factor  favouring  retention  of 
gastric  contents  leading  first  to  atonic  dilatation  and  secondly 
to  ptosis.  Cases  of  congenital  stenosis  may  long  resist 
marked  ptosis,  and  the  condition  be  only  discovered  when 
the  individual  is  well  on  towards  middle  life  or  even  older. 

A  factor  which,  it  has  seemed  to  me,  has  a  determining 
mfluence  on  the  time  at  which  symptoms  become  pronounced 
and  continuous  is  the  degree  of  mobility  of  the  pylorus.  In 
some  persons  it  seems  as  if  the  pylorus  were  congenitally 
fixed,  and  even  fixed  abnormally  high  in  the  abdomen, 
with  the  result  that  even  moderate  dilatation  wiU  at  once 
give  rise  to  symptoms  of  retention.  In  other  cases  the 
pylorus  moves  somewhat  freely  to  the  right  or  downwards 
and,  when  this  movement  corresponds  with  and  is  determined 
by  the  condition  of  the  stomach,  symptoms  of  retention 
do  not  so  readily  assert  themselves  and  the  condition,  as 
a  consequence,  may  be  long  overlooked.  I  have  seen,  as 
m  Fig.  8,  with  extreme  ptosis  of  long  duration,  and  due 
seemingly  to  a  congenitally  small  pylorus,  the  pylorus  at  the 
level  of  the  umbilicus.  I  have  seen  considerable  ptosis  with 
the  pylorus  high  up  and  apparently  so  fixed  as  not  likely  to 
fall  ;  in  these  cases  symptoms  become  prominent  early. 

It  is  possible  that  congenital  stenosis  may  be  the  cause 
of  aU  the  extreme  cases  of  ptosis  ;  but  attention  has  not  been 
sufficiently  long  directed  to  these  two  conditions,  either 
separately  or  together,  to  determine  whether  or  no  this  be 
the  case.  Fig.  8  is  from  a  case  which  occurred  when 
abdominal  surgery  was  in  its  infancy. 


GASTROPTOSIS— ILLUSTRATIVE  CASES        89 

Illustrative  Cases. 

Congenital  Pyloric  Stenosis  :  Gastroptosis  : 
Operation  Successful 

Case  12. — Mrs.  R.,  33  years  of  age,  was  admitted  to  the 
Ro3'al  Infirmary  on  the  27th  April,  1909.  The  history  was  that 
in  childliood  she  was  subject  to  what  was  called  "  bilious 
attacks,"  which  were  characterized  by  headache,  which 
confined  her  to  bed  for  a  day  or  so,  was  followed  by  vomiting, 
which  relieved  her.  From  the  age  of  18  she  had  been 
definitely  troubled  with  her  stomach.  The  symptoms 
were  flatulence,  water-brash,  and  acid  eructations.  As  a 
riile  there  was  no  pain  unless  she  had  eaten  vegetables, 
soup,  new  bread,  doughy  puddings,  or  anything  spiced.  When 
pain  occurred  it  came  on  two  or  three  hours  after  food  and 
was  referred  to  the  epigastrium  and  shot  through  to  the 
back.  It  lasted  for  half  an  hour  or  an  hour,  and  was  relieved 
for  a  time  by  a  hot  drink.  Patient  did  not  vomit  unless 
the  pain  was  accompanied  by  a  "  bilious  attack,"  which  it 
occasionally  was.  After  every  meal  she  had  a  feeling  of 
weight  in  the  stomach  and  flatulence  (distension)  so  that 
she  wanted  to  loosen  her  clothing.  The  diet  which  she 
found  suited  her  best  was  stale  bread  or  scones,  soft-cooked 
eggs,  a  mutton  chop,  porridge  occasionally,  strained  soups, 
and  fairly  strong  tea.  She  continued  in  this  way  having 
occasional  exacerbations  when  the  diet  just  mentioned 
did  not  agree  with  her.  For  four  years  she  had  been 
troubled  with  attacks  of  vomiting  ;  she  would  vomit  every 
day  for  eight  or  nine  days,  and  then  be  free  from  it  for 
perhaps  six  months.  The  attacks  of  vomiting  were  preceded 
by  loss  of  appetite,  by  the  feeling  of  "  a  great  load  in  the 
stomach,"  water-brash,  and  acid  eructations.  The  vomited 
material  was  clear  and  watery,  had  a  very  bad  smell,  and 
was  very  great  in  amount.  The  vomiting  occurred  every 
half  hour  or  hour  for  three  or  four  times.  The  vomiting 
often  occurred  between  three  and  four  o'clock  in  the  morning, 
although  neither  tea  nor  supper  had  been  taken.     A  year 


90  THE  STOMACH 

later,  during  the  last  two  days  of  a  five-day  attack,  the 
vomit  was  black  in  colour.  After  this  attack  the  hands 
were  apparently  in  a  state  of  tetany.  The  vomit  was  not 
black  again  until  July,  1908.  In  December,  1908,  she  had 
an  attack  of  vomiting  of  clear  fluid  for  four  days,  then  an 
interval  of  two  days  without  vomiting,  and  then  two  days 
of  vomiting  of  very  black  material.  After  this  attack  she 
had  contracture  (tetany)  of  both  hands  with  numbness  and 
tingling  in  the  lower  limbs.  In  the  first  week  of  February 
she  had  another  attack,  which  lasted  four  days,  and  was 
followed  by  tetany  with  stiffness  in  the  jaw  in  addition  to 
stiffness  in  the  limbs.  She  had  another  attack  of  vomiting 
on  the  31st  March,  and  another  on  the  25th  April.  She 
was  admitted  to  hospital  on  the  27th.  She  had  always 
suffered  from  constipation. 

Condition  on  Admission. — The  patient  was  a  spare 
woman  about  5  ft.  in  height,  and  weighing  5  st.  li  lb. 
There  was  no  abnormal  condition  in  the  thoracic  organs. 
The  abdomen  was  scaphoid  in  shape  and  emaciated. 
Peristaltic  movements  were  visible  over  what  appeared  to 
be,  and  was  easily  demonstrated  to  be,  the  stomach.  When 
the  organ  contracted,  it  made  a  visible  swelling  and  pro- 
jection on  the  abdominal  wall,  and  in  this  swelling  the 
peristaltic  movements  were  seen  to  pass  from  above  down- 
wards and  to  the  right.  The  outline  of  the  stomach  as 
determined  by  percussion  and  succussion  was  mapped  out 
from  time  to  time  and  the  two  tracings  given  on  opposite 
page  show  the  changes  in  its  position  and  size,  judging  from 
the  position  of  the  umbilicus. 

On  the  day  of  admission  and  the  following  day  the 
patient  vomited.  She  was  kept  in  bed  and  put  on  peptonized 
milk  and  peptonized  arrowroot  and  milk,  four  ounces  of 
each  every  alternate  two  hours.  The  bowels  were  regulated 
by  a  pill  of  cascara,  nux  vomica,  and  belladonna.  The 
stomach  symptoms  improved  and  the  organ  diminished  in 
size  and  was  not  so  low  in  the  abdomen,  and  we  hoped  that 
she  might  go  on  improving,  but  when  we  got  improvement 
to  a  certain  point  the  symptoms  would  all  come  back  ;  she 


GASTROPTOSIS— ILLUSTRATIVE  CASES 


91 


became  sick  and  vomited,  and  the  ptosis  and  relaxation 
became  as  bad  as  before.  We  worked  away  with  this  case 
for  nearl}^  two  months,  sometimes  being  encouraged  with 
the  result  of  treatment ;  but,  as  has  been  said,  beyond  a 
certain  point  we  could  not  carry  improvement,  and  even 
that  point  was  too  unstable  to  be  of  any  value.  I  was 
anxious  to  give  this  patient  every  possible  chance  of  getting 
well  without  operation,  although  I  did  not  believe  it  could 
be  done.  The  reason  for  this  scepticism  lay  in  my  belief 
that  there  was  almost  certainly  a  congenital  pyloric  stenosis, 


© 


© 


A 


Tracings  of  Case  12. 


Fig.    9. — U,    Umbilicus;  n.  Ant. 
iliac  spine ;     0,  Mammas. 


Fig.  10. — U,  Umbilicus;  n,  Ant. 
iliac  spine ;  0,  Mammae. 


or,  at  all  events,  a  long-standing  difficulty  at  or  near  the 
pyloric  outlet,  which  had  led  to  this  great  measure  of  ptosis 
in  a  woman  of  thirty-three  years.  She  was  quite  willing 
to  submit  to  operation.  My  colleague,  Mr.  David  Wallace, 
now  Sir  David  Wallace,  opened  the  abdomen  late  in  June,  and 
found  the  stomach  and  pylorus  in  the  condition  we  have 
indicated.  He  performed  a  gastro-enterostomy.  The  result, 
however,  was  exceedingly  disappointing  for,  after  she  was 
allowed  to  take  nutriment  into  the  stomach,  vomiting 
became  as  bad  and  even  worse  than  it  had  been  before.     It 


92  THE  STOMACH 

was  evident  therefore,  that  the  new  opening  was  not  draining 
the  stomach.  The  patient's  condition  became  critical,  and 
Mr.  Wallace  decided  to  re-open  the  abdomen  and  to  repeat 
the  operation  of  gastro-enterostomy  if  it  seemed  desirable. 
Another  gastro-enteric  opening  was  made,  which  proved 
thoroughly  efficient,  and  from  this  operation  an  excellent 
recovery  was  made  without  any  recurrence  of  gastric 
trouble.  She  could  eat  any  kind  of  food  without  discomfort 
and  rapidly  put  on  weight. 

Hyperchlorhydria  :    Gastric  Ulcer  :    Ulcer  Healed  : 
Ptosis  :  Successful  Operation 

Case  13. — Mrs.  A.,  aged  47,  illustrates  this  sequence  of 
events  very  clearly.  She  was  admitted  to  the  Royal  Infirmary 
on  the  7th  September,  on  the  recommendation  of  Dr.  Angus 
McDonald.  The  history  was  that  for  about  seven  years 
she  had  suffered  from  pain  referred  to  the  stomach,  coming  on 
one,  one  and  a  half,  or  two  hours  after  food.  This  pain 
often  passed  off  without  anything  being  done  for  it ;  at 
other  times  it  was  more  severe  and  relief  was  only  obtained 
by  vomiting,  which  was  induced  by  putting  a  finger  into  the 
throat.  The  vomited  matter  consisted  of  part  of  the  previous 
meal  and  was  usually  very  sour.  She  often  relieved  the  pain 
by  taking  baking  soda  in  hot  water,  and  she  sometimes  took 
this  three  times  a  day.  Pain  might  come  on  after  any  meal, 
but  the  worst  attacks  occurred  after  dinner.  Tea  in  the 
afternoon  did  not  increase  the  pain,  indeed  often  eased  it. 
She  was  often  for  months  on  end  free  from  stomach  trouble, 
whilst  not  dieting  herself  in  any  particular  way,  and  indeed 
when  taking  ordinary  fare.  The  periods  of  pain  lasted  for 
from  two  to  four  months,  never  under  two.  The  year  before 
admission  an  attack  came  on  in  May  and  lasted  until  the  second 
week  in  October  :  during  this  period  she  would  have  a  few 
days  of  freedom  from  time  to  time.  When  the  pain  came 
on  it  gradually  became  worse  until  she  felt  as  if  her  "  breast 
(stomach)  would  split."  An  attack  began  by  a  lump  rising 
in  her  throat,  and,  if  she  could  "  break  "  it,  water  poured 
from  her  mouth  ;   then  she  vomited,  as  a  rule,  and  at  once 


GASTROPTOSIS— ILLUSTRATIVE  CASES        93 

got  relief  ;  the  vomit  always  contained  food.  From  the 
middle  of  October  to  May  she  was  quite  free  of  pain  or  dis- 
comfort and  could  eat  anything,  "  soups  of  an}^  kind,  suet 
pudding,  and  potatoes. ' '  In  May  symptoms  began  again  with 
the  feeling  of  a  lump  in  the  epigastrium,  rising  up  into  the 
throat  and  making  her  feel  as  if  she  would  choke  ;  then  the 
lump  would  break  with  a  discharge  of  clear  water  from  the 
mouth.  This  would  last  for  a  few  days  and  then  the  pain 
would  set  in.  If  she  took  baking  soda  she  felt  as  if  "  the 
bowels  rolled  over,"  and  she  vomited  quite  easily,  at  other 
times  vomiting  was  induced  by  putting  the  finger  in  the 
throat,  while  sometimes  the  pain  passed  off  without 
vomiting.  These  symptoms  continued  from  May  until 
admission.  She  never  vomited 
anything  suggestive  of  blood. 
For  twelve  months  there  had 
been  constipation.  She  never 
passed  blood,  or  noticed  the 
motions  black  or  brown  in 
colour.  The  pain  was  always 
in  the  pit  of  the  stomach  and  \     -... 

never    went    through   to   the  '^•*-..„ •''' 

back.      She    usuahy    became 

very  hungry  after  vomiting :        ^  ^ 

sometimes  the  hunger  craving     Fig.    n.— Case   13.     stomach  re- 
.    ,  i.1     J.    1  11  cumbent;  U,  umbilicus. 

was  so  mtense  that  she  would 

buy  apples  from  a  street  vendor  and  eat  them  ;  she  said  she 
felt  she  would  go  crazy  if  she  did  not  buy  and  eat  !  Porridge, 
oatcakes  and  tea,  fish  and  potatoes,  and  potato  soup  always 
made  her  worse  during  these  months. 

This  patient  was  shown  at  a  post-graduate  clinic  on  the 
15th  September.  The  stomach  projected  and  its  peristaltic 
movements  were  visible.  K  rough  outline  of  the  body  of 
the  stomach  was  marked  out  by  aid  of  percussion  and 
succussion  :  the  outline  is  shown  in  Fig.  11.  From  this  it 
was  evident  that  there  was  definite  ptosis,  but,  as  the 
pylorus  also  was  displaced  downwards,  I  was  of  opinion 
that  a  factor,  in  addition  to  ptosis,  was  required  to  explain 


94  THE  STOMACH 

the  severity  and  the  long  continuance  of  the  symptoms, 
A  cicatrized  ulcer  near  the  pylorus  was,  in  my  judgment, 
the  most  likely  additional  factor.  There  was  free  hydro- 
chloric acid  in  the  gastric  contents.  I  did  not  think  it 
worth  while  to  spend  time  in  trying  to  remedy  the  condition 
by  careful  feeding,  massage,  and  lavage,  so  advised  her  to 
have  an  operation.  To  this  she  consented,  and  the  operation 
was  performed  by  my  colleague,  Mr.  Wallace,  on  15th  October. 
The  puckering  caused  by  a  healed  gastric  ulcer  near  the 
pylorus  was  shown  at  the  operation.  Mr.  Wallace  performed 
a  gastro-enterostomy  and  the  patient  left  hospital  on  the 
2nd  November  feeling  very  well,  able  to  take  a  good  meal, 
and  very  grateful  for  the  relief  she  had  obtained. 

Remarks. — This  patient  was  a  most  intelligent  woman, 
as  was  shown  by  the  clearness  with  which  the  history  of  her 
gastric  troubles  had  been  given.  From  that  history  it  is 
clear  that  her  early  symptoms  were  typical  of  hyperchlor- 
hydria.  During  the  year  preceding  the  year  of  admission 
the  long  duration  of  symptoms  suggested  that  at  that  time 
she  probably  had  an  ulcer  near  the  pylorus,  which  must  have 
healed,  seeing  that  the  winter  months  had  been  so  entirely 
free  of  discomfort.  Her  functional  troubles  recurred, 
associated  with  dilatation  and  ptosis,  the  symptoms  being 
intensified  by  the  scar  near  the  pylorus.  Had  she  been  in 
a  position  to  spend  months  over  the  restoration  of  the  stomach 
to  the  condition  it  had  been  in  during  the  previous  winter, 
and  had  she  been  so  placed  socially  that  she  could  have 
paid  continuous  attention  to  having  a  suitable  dietary, 
aided  by  equally  suitable  medical  supervision,  life  might 
have  been  made  quite  tolerable  for  her  ;  but,  under  the  cir- 
cumstances, the  treatment  advised  was  in  my  judgment 
the  only  wise  course.  The  stomach  and  duodenum  were 
of  course  examined  with  a  view  to  excluding  any  fresh 
ulceration,  and  in  view  of  the  negative  result  of  the  examina- 
tion we  consider  that  this  case  is  an  additional  proof  of 
our  contention  that  hyperchlorhydria  may  lead  to  gastric 
ulcer,  that  that  ulcer  can  heal,  that  symptoms  may  pass 
away  and  return  without  any  new  ulcer  having  formed  ; 


GASTROPTOSIS— TREATMENT  95 

and  therefore  that  the  doctrine  of  hyperchlorhydria  being 
caused  by  ulcer  is  erroneous  and  misplaces  cause  and  effect. 

Treatment. — The  treatment  to  be  adopted  will  depend 
upon  the  degree  of  displacement.  In  the  lesser  or  moderate 
degrees  of  the  condition  the  treatment  applicable  to  dilatation 
is  suitable.  Food  in  small  bulk,  finely  divided,  and  easily 
and  rapidly  digested  ought  to  be  taken.  The  patient  ought 
to  lie  down  for  two  hours  or  more  after  meals.  Sometimes 
benefit  is  obtained  and  comfort  is  afforded  by  an  abdominal 
belt,  especially  the  obstetric  type  of  belt  with  the  pressure 
on  the  lower  part  of  the  abdomen  so  applied  as  to  help  to 
hold  up  the  intestines,  supplementing  the  support  supplied 
by  the  anterior  abdominal  wall.  Massage  of  the  muscles 
of  the  abdomen  will  help  to  strengthen  the  muscles  them- 
selves, and  if  by  the  addition  of  prolonged  rest  and  liberal 
feeding  the  subcutaneous  fat  can  be  increased  the  benefit 
may  be  still  greater.  It  is  most  desirable  that  the  condition 
should  be  seriously  dealt  with  in  its  earlier  stages  and  such 
measures  as  have  been  indicated  taken  to  cure  it.  If 
patient  and  wisely  directed  treatment  on  the  lines  indicated 
does  not  lead  to  restitution  of  the  organ  to  its  normal 
position  and  condition,  gastro-enterostomy  ought  to  be 
advised.  The  advantage  of  the  operation  is  that  the 
emptying  of  the  stomach  is  facilitated.  Still,  if  suitable 
treatment  be  available  it  ought  to  have  a  reasonably  long 
trial  before  recourse  is  had  to  surgical  measures.  In  extreme 
cases,  however,  the  outlook  is  gloomy,  and  it  is  very 
doubtful  if  treatment  at  best  can  be  more  than  palliative. 
It  may  be  more  definitely  stated  that  the  relief  and  the 
improvement  which  foUow  on  gastro-enterostomy  when 
cases  are  properly  selected,  are  very  striking.  To  my  mind 
the  only  possible  explanation  of  the  improvement  is  that  the 
gastric  contents  rapidly  drain  through  the  new  opening 
whenever  the  stomach  wall  relaxes  from  its  peristalsis. 
This  almost  certainly  prevents  further  ptosis  ;  although  to 
what  extent  it  may  favour  the  return  of  the  stomach  to 
normal  size  and  position  cannot  be  definitely  predicted,  for 
these  apparently  varj^  in  different  cases. 


96  THE   STOMACH 

That  the  passage  of  the  food  from  the  stomach  directly 
into  the  jejunum  does  not  lead  to  inefficient  digestion  is 
shown  by  the  great  increase  in  weight  that  rapidly  follows 
upon  the  operation. 

A  point  which  is  worthy  of  emphasizing  is  the  necessity 
of  seeing  that  the  lowest  part  of  the  stomach  is  the  point 
selected  for  communicating  with  the  jejunum.  In  Case  12 
it  was  shown  that  unless  this  was  secured  relief  did  not 
follow ;  while  the  relief  that  followed  upon  the  second 
operation  proved  that  the  efficient  drainage  of  the  stomach 
is  really  the  mechanical  basis  on  which  the  therapeutic 
success  of  the  operation  depends.  Recently  one  of  my  surgical 
colleagues  asked  me  to  examine  a  patient  on  whom  he  had 
some  time  before  performed  a  gastro-enterostomy  with 
success  and  with  great  relief  to  the  patient.  Owing 
apparently  to  want  of  sufficient  care  some  of  the  old  symptoms 
were  reappearing  and  this  seemed  to  me  to  be  due  to  a 
measure  of  gastric  dilatation  which  brought  the  lowest  part 
of  the  stomach  below  the  level  not  only  of  the  pylorus  but 
of  the  gastro-enterostomy  opening.  He  was  again  suffering 
from  symptoms  of  retained  food  residuum.  The  lesson 
to  be  learnt  was  that  with  moderate  care  such  dilatation 
would  not  occur,  and  that,  when  dilatation  was  not  present, 
the  artificial  opening  would  efficiently  drain  the  viscus. 

Whatever  theoretical  contentions  have  been  advanced 
to  show  the  unreasonableness  of  adopting  a  procedure  which 
seemed  to  run  counter  to  our  knowledge  of  the  digestive 
processes  in  the  upper  parts  of  the  gastro-intestinal  tract, 
the  results  are  such  as  to  warrant  fully  the  acceptance  of 
the  treatment  on  empirical  grounds. 

The  two  cases  to  which  reference  has  just  been  made 
suggest  the  thought  that  some  of  the  cases  of  "  vicious 
circle  "  which  have  been  recorded  may  have  had  as  their 
true  cause  the  failure  of  the  artificial  channel  to  act  as  an 
efficient  drain  for  the  stomach  contents. 


CHAPTER    X 

PYLORIC     STENOSIS,     ESPECIALLY    CONGENITAL    STENOSIS     IN 

THE   ADULT 

Pyloric  Stenosis  i 

In  approaching  the  subject  with  which  this  chapter  deals 
the  generally  recognized  causes  of  pyloric  stenosis  may  be 
enumerated.  They  are  (i)  ulcer,  (2)  cicatrix,  and  (3) 
malignant  disease. 

Pyloric  Spasm. — That  any  of  these  three  conditions  may 
cause  recurring  spasm  contraction  of  the  pylorus  will  not 
be  questioned  by  any  sound  clinical  pathologist.  That  the 
spasm  is  due  to  local  irritation  will  be  generally  conceded  ; 
while  the  further  proposition,  that  the  spasm  is  an  important 
factor  in  occluding  the  pyloric  outlet,  will  be  readily  accepted 
by  clinicians  who  have  watched  such  cases  with  any  reason- 
able measure  of  interest. 

That  pyloric  spasm  may,  in  addition  to  the  causes  just 
enumerated,  be  also  determined  by  the  direct  stimulation 
or  irritation  produced  by  the  chemical  character  or 
mechanical  state  of  the  gastric  contents  upon  the  unbroken 
pyloric  wall  will  not  meet  with  such  general  acceptance  ; 
while  probably  only  few  clinicians  have  confirmed  Lauder 
Brunt  on' s  2  observation  that  pyloric  spasm  may  accompany 
migraine,  and  be  but  an  additional  manifestation  of  an 
explosive  neurosis. 

Effect  of  Pyloric  Stenosis. — Without  going  into  details, 
which  are  unnecessary,  it   may  be    noted   that   the   main 

1  Reprinted  from  the  British  Medical  Journal,  nth  July,  190S,  with 
some  alterations. 

-  Lauder  Brunton,  AUbutt's  System  of  Medicine,  vol.  iii. 

97  7 


98  THE   STOMACH 

result  or  manifestation  of  stenosis  is  stomach  dilatation 
or  ptosis.  The  size  and  position  of  the  stomach  can,  as  a 
rule,  be  easily  determined  by  physical  examination  ;  while 
the  recurring  vomiting  demonstrates  the  retention  in  the 
stomach  of  material  which,  under  normal  circumstances, 
is  readily  passed  on  into  the  duodenum. 

A  further  and  a  very  important  manifestation  of  pyloric 
stenosis  is  visible  stomach  peristalsis.  This,  when  present, 
at  once  excludes  the  possibility  of  the  dilatation  or  ptosis 
being  due  to  muscular  atonicity  resulting  from  catarrh, 
anaemia,  or  nervous  debility.  It  is  only  in  pyloric  obstruction 
associated  with  the  retention  of  considerable  power  in  the 
muscular  wall  of  the  viscus,  that  this  symptom  will  be 
noted  ;  and  in  my  experience  such  a  loss  of  power  only 
occurs  in  extreme  cases,  which  are  either  cases  in  which 
there  has  been  a  long  history  of  gastric  trouble,  or  are 
malignant,  with  a  relatively  rapid  progressive  debility  and 
a  correspondingly  short  history.  Where  definite  pyloric 
swelling  is  palpable  the  merest  tiro  in  clinical  medicine  has 
no  difficulty  in  ascribing  the  gastric  symptoms  to  pyloric 
obstruction. 

Congenital  Stenosis  an  Additional  Cause  of 
Pyloric  Obstruction  in  the  Adult 

From  the  preceding  summary  I  hope  it  may  be  con- 
ceded that  I  approach  the  subject  of  congenital  stenosis  of 
the  pylorus  in  the  adult  with  sound  views  regarding  pyloric 
stenosis  in  general,  and  I  turn  now  to  the  special  theme  of 
this  communication. 

We  may  begin  with  the  historical  side  ;  and  we  need 
not  too  seriously  concern  ourselves  with  the  question  as  to 
who  recorded  the  first  case.  John  Thomson  ^  ascribed  it  to 
Williamson  of  Leith  in  1841,  Osier  2  has  put  it  back  to  Dr. 
Hezekiah  Beardsley  in  1788  ;  further  research  may  put  it 
back  into  the  still  darker  ages  of  medicine.  For  our  present 
purpose  it  is  not  profitable  to  go  beyond  the  years  1879  and 

^  John  Thomson,  Scot.  Med.  and  Surg.  Jottrn.,  June,  1897. 
2  Osier,  referred  to  by  Cautley  and  Dent. 


CONGENITAL   STENOSIS   IN   THE   ADULT 


99 


1885.  In  the  former  year,  1879,  Heinrich  Landerer  1 
published  the  thesis  submitted  by  him  for  the  doctorate  of 
medicine  of  the  University  of  Freiburg.  It  was  entitled 
Congenital  Stenosis  of  the  Pylorus.  After  referring  to  the 
hitherto  known  causes  of  pyloric  stenosis  and  gastric 
dilatation,  he  proceeded  to  show  that  there  was  an  additional 
condition  to  those  he  had  enumerated — namely,  one  in 
which  the  stenosis  was  congenital.  He  supported  this 
thesis  by  giving  details  of  ten  instances  in  which  he  noted 
pyloric  narrowing.  The  first  case  observed  was  a  man  of 
45  years,  who  had  been  for  years  in  the  hands  of  doctors  on 
account  of  stomach  disorder.  After  death  it  was  found  that 
he  had  an  enormously  dilated  stomach  without  structural 
change,  no  thickening  at  the  pylorus,  and  yet  a  pyloric 
outlet  so  small  as  to  measure  only  2  mm.  This  led  to  the 
careful  examination  of  the  condition  of  the  pylorus  in  other 
bodies.  The  result  was  that  he  collected  other  nine  instances 
of  narrowing  in  persons  ranging  in  age  from  43  to  63  years. 
The  degree  of  stenosis  varied.  Although  it  was  only  in  the 
first  case  that  a  previous  history  was  available,  his  clinical 
acumen  led  him  to  realize  that  this  was  a  condition  which 
must  be  of  importance  to  the  clinician. 

In  1885  Professor  Rudolf  Maier  2  of  Freiburg  published  in 
Virchow's  Archiv  a  contribution  to  the  same  subject.  He 
gave  a  short  account  of  thirty- one  cases  in  which  he  had 
found  a  pyloric  stenosis  which  he  believed  to  be  congenital. 
The  observations  were  made  at  post-mortem  examinations,  his 
attention  having  been  drawn  to  the  matter  by  a  striking 
example  of  the  condition  having  occurred  in  one  of  his 
patients.  The  cases  varied  in  age  from  12  to  75  years. 
The  degree  of  narrowing  of  course  varied  considerably, 
but  in  none  was  the  narrowing  associated  with  what  we 
would  caU  a  coarse  structural  lesion.  As  the  result  of 
these  observations  he  separated  his  cases  into  two  groups  : 
First,    a   simple   form ;     second,,  a    combined   form.     The 

1  Landerer,  Ueber  angeborene  Stenose  des  Pylorus,  Tubingen,  1879 

2  Maier,  "Beitrage  zur  angeborenen  Pylorus-stenose,"  Virchow's  Arch., 
1SS5,  Bd.  cii.  S.  413. 


loo  THE  STOMACH 

second  group  contained  the  cases  in  which,  in  addition  to 
stenosis,  there  was  thickening  of  the  pylorus.  With  regard 
to  the  first  group,  where  narrowing  was  present  without 
other  change  at  the  pylorus,  he  did  not  think  there  was 
reasonable  room  for  doubt  that  they  were  congenital ; 
those  in  which  there  was  pyloric  thickening  in  addition  to 
narrowing  he  examined  more  fully  and  argued  more  closely 
in  support  of  their  congenital  nature. 

This  argument  we  need  not  follow  now,  for  later  develop- 
ments have  strengthened  his  contention  that  a  combined 
form  is  met  with  in  the  adult.  At  the  same  time,  the 
subject  cannot  be  left  without  indicating  that  the  description 
of  the  changes  he  observed  will  be  found  well  worthy  of 
attention  from  those  specially  interested  in  the  exact 
anatomical  appearances  presented  by  them. 

Congenital  Hypertrophic  Stenosis  in  Infants 

The  next  important  step  was  the  recognition  that  the 
condition  now  known  as  hypertrophic  pyloric  stenosis  in 
infants  was  a  pathological  fact  and  a  clinical  entity. 
Hirschsprung  i  in  1888  seems  to  have  been  the  first  to 
describe  the  condition  ;  but  many  members  of  the  profession 
probably  first  had  their  attention  drawn  to  the  subject  by 
John  Thomson's  2  paper  published  in  1897.  Since  those 
dates  the  flood  of  literature  on  the  subject  has  attained 
portentous  proportions.  It  is  no  part  of  my  present  purpose 
to  deal  with  that  literature,  or  with  the  differences  of  opinion 
which  have  risen  up  around  the  etiology  of  the  condition — 
that  may  be  left  in  the  hands  of  the  protagonists  already  in 
the  field.  It  may,  however,  be  taken  as  established  that  there 
is  met  with  early  in  infant  life  a  stenosis  of  the  pylorus  due 
to,  or  accompanied  by,  marked  thickening  of  the  muscle 
of  the  pylorus  ;  that  the  condition  is  commonly  regarded 
as  congenital,  and  is  described  as  congenital  hypertrophic 
stenosis  in  infants. 

1  Hirschspriing,  quoted  b}'  Bloch,  Jahrhuch  fur  Kinderheilkunde,  1907, 
Ixv.  S.  337. 

2  John  Thomson,  loc.  cit. 


HYPERTROPHIC   STENOSIS   IN    INFANTS      loi 

It  does  not  appear,  so  far  as  a  cursory  look  through 
some  of  the  hterature  has  disclosed,  that  any  other  form 
of  stenosis  has  been  observed  in  infants  ;  that  is  to  say, 
there  are  no  examples  of  the  class  Maier  called  simple 
stenosis. 

The  hypertrophic  stenosis  is  much  the  same  as  Maier's 
Combined  Form.  It  is  so  easy  of  recognition  in  extreme 
cases  that  one  wonders  now  that  clinicians  had  not  recognized 
it  long  before. 

On  that  lack  of  observation  on  the  part  of  clinical 
pathologists  it  is  not  necessary  to  enlarge.  It  is,  however, 
necessary  to  claim  that  in  a  condition  of  this  type  there 
must  of  necessity  be  degrees  of  stenosis  and  degrees  of 
thickening.  AU  infants  with  hypertrophic  stenosis  of  the 
pylorus  do  not  die.  Only  the  severe  cases  are  seen  by 
the  expert,  and  it  is  only  for  them  that  surgical  aid  is 
required. 

That  aU  cases  have  not  the  same  measure  of  pyloric 
narrowing,  and  therefore  do  not  show  equally  urgent  clinical 
symptoms  wiU  presumably  be  granted  as  a  sound  proposition. 
In  support  of  the  proposition  there  indeed  emerges  from  the 
literature  what  to  my  mind  is  an  illuminating  difference  of 
opinion.  It  is  this  :  Controversy  has  arisen  as  to  the  part 
that  spasm  of  the  pylorus  takes  in  the  production  of  the 
hypertrophy  and  of  the  stenosis.  Pfaundler  i  goes  far 
when  he  holds  that  the  condition  is  entirely  one  of  local 
cramp  or  spasm,  and  that  it  can  be  successfully  combated 
by  medicinal  and  dietetic  measures.  Pfaundler's  contentions 
are  based  on  clinical  observation,  and,  as  such,  they  belong 
to  the  data  on  which  judgment  has  to  be  founded.  At  the 
same  time,  if  I  do  not  question  his  observations,  neither 
do  I  question  the  observations  of  those  who  have  had 
experience  of  cases  unrelieved  by  dietetic  or  medicinal 
measures,  and  imperatively  requiring  surgical  measures  for 
the  relief  of  a  permanent  and  structural  obstruction. 

From  this  it  must  be  inferred  that  there  are  degrees  of 
stenosis,   and  that  a  pyloric  stenosis  is  not  incompatible 

^  Pfaundler,  Wien.  klin.  Woch.,  Nr.  45,  1898,  p.  1025. 


I02  THE   STOMACH 

with  infant  life  ;    that  in  spite  of  its  presence  hfe  may  be 
continued  into  childhood  and  even  onwards. 

Simple  Stenosis  in  Infants. — That,  so  far  as  I  know, 
there  is  no  recognition  in  infancy  of  what  Maier  calls  simple 
stenosis  is  to  me  inexplicable,  and  when  cases  begin  to  be 
recorded  of  simple  stenosis  of  the  pylorus  being  found  in 
children  of  6  years  when  on  the  operating  table,  it  is  at 
least  suggestive  that  there  is  a  clinical  hiatus  which  ought 
not  to  be  difficult  to  fill. 

The  Present  Medical  Position 

When  we  inquire  into  the  position  congenital  stenosis  of 
the  pylorus  in  the  adult  occupies  in  the  realm  of  clinical 
medicine  at  the  present  moment,  there  are  facts  to  be  noted 
which  have  considerable  significance.  The  article  on 
dilatation  of  the  stomach  i  in  AUbutt's  System  of  Medicine, 
is  from  the  pen  of  the  erudite  editor  himself,  but  there  is  no 
mention  of  this  condition  amongst  the  causes  of  dilatation. 

Sidney  Martin  ^  and  Hemmeter  ^  do  not  mention  the 
condition.  Ewald,*  quoting  Landerer  and  Maier,  includes 
congenital  stenosis  amongst  the  mechanical  constrictions 
met  with  at  the  pylorus.  Van  Valzah  and  Nisbet  ^  recognize 
congenital  pyloric  stenosis  in  infants,  and  state  that,  with 
the  observance  of  a  proper  diet,  they  may  live  into  adult  life. 

Lambert  and  Foster,  6  writing  in  1907  on  benign  stenosis 
of  the  pylorus,  do  not  mention  the  congenital  form. 

Riegel,7  writing  in  1908,  only  refers  to  congenital 
narrowing  of  the  pylorus  as  due  to  muscular  hypertrophy 
of  the  pylpric  sphincter,  and  as  leading  to  early  death. 

Boas,8   writing    in    1907,    merely   mentions   congenital 

^  Clififord  Allbutt,  System  of  Medicine,  vol.  iii. 
^  Sidney  Martin,  Diseases  of  the  Stomach,  1895. 
=*  Hemmeter,  Diseases  of  the  Stomach,  1898. 

*  Ewald,  Diseases  of  the  Stomach,  second  German  edition,  1892,  p.  125. 
"•'  Van  Valzah  and  Nisbet,  Diseases  of  the  Stomach,  1899. 

*  Lambert  and  Foster,  "Benign  Stenosis  of  the  Pylorus,"  Amer. 
Joitrn.  Med.  Sci.,  1907,  vol.  134,  p.  335. 

'  Riegel,  Die  Erkrankungen  der  Magens,  1908,  II  Teil,  S.  220. 

*  Boas,  Diagnostik  und  Therapie  der  Magenkrankheiten,  II  Teil,  1907, 
S.  168. 


THE   PRESENT   SURGICAL    POSITION         103 

pyloric  stenosis  in  the  adult,  and  passes  on  to  the  consideration 
of  other  causes  of  stenosis. 

Osier  1  asks  if  some  of  the  cases  of  dilated  stomach  with 
thickening  or  hypertrophy  of  the  pylorus  may  not  be 
congenital. 

The  Present  Surgical  Position 

When  we  turn  to  the  surgical  side  of  the  literature  dealing 
with  the  abdomen,  the  following  may  be  quoted  : 

Cautley  and  Dent  2  refer  to  three  cases  as  suggesting  a 
congenita]  origin,  occurring  at  the  ages  of  6,  11,  and  22. 

Mayo  Robson  and  Moynihan,^  after  reviewing  and 
discussing  the  literature  on  congenital  hypertrophic  stenosis, 
conclude  as  follows  :  "  There  can  be  little  hesitation  in 
affirming  that  a  congenital  abnormality  of  the  pylorus  of 
some,  at  present  indeterminate,  character  may  after  the  lapse 
of  few  or  many  years  be  so  altered,  or  added  to,  as  to  cause 
symptoms  of  pyloric  obstruction.  The  conditions  and 
the  frequency  of  such  cases  require  further  investigation." 
Mr.  Mayo  Robson,  in  his  large  experience,  had  only  operated 
on  one  such  case  at  the  date  of  writing,  the  patient  being  a 
young  man  of  24  years. 

Maylard  *  of  Glasgow  in  1903  wrote  a  paper  that  has  not 
received  the  attention  in  this  country  to  which  it  was 
entitled,  on  "  Congenital  Narrowness  of  the  Pyloric  Orifice." 
The  paper  is  based  upon  observations  made  when  the 
abdomen  had  been  opened  for  "  chronic  gastric  derange- 
ment." The  condition  of  the  pyloric  orifice  in  those  cases 
was  not  only  sufficient  to  explain  the  symptoms  which 
existed,  but  "  to  suggest  that  the  condition  itself  was 
probably  of  congenital  origin."  In  1904  he  recorded  another 
case,  a  man  aged  31,  in  whom  at  the  time  of  operation  he 
found  a  hypertrophic  stenosis  of  the  pylorus,  which  he  believed 

^  Osier,  Practice  of  Medicine,  igoi.  ■ 

-  Cautley  and  Dent,  Tratis.  Roy.  Med.  and  Chi.  Soc,  vol.  Ixxxvi., 
December,  1902. 

3  Mayo  Robson  and  Moynihan,  Diseases  of  the  Stomach,  second  edition, 
1904. 

*  Maylard,  Clin.  Soc.  Trans.,  vol.  xxxvii.,  London,  1904-  P-  ^3- 


104  THE  STOMACH 

to  be  congenital,  presenting  the  "  funnel-shape "  type 
described  by  Maier. 

In  none  of  the  cases  recorded  does  it  appear  that  any 
attempt  had  been  made  at  a  differential  diagnosis  before 
the  patient  was  submitted  to  operation. 

When  Landerer  and  Maier  wrote,  the  surgery  of  the 
abdomen  had  not  entered  upon  the  brilliant  operating 
epoch  included  in  the  last  twenty  years  ;  and  although  they 
both  insisted  on  the  great  value  of  differential  diagnosis, 
the  success  of  surgical  operations  on  the  stomach  may  be 
said  to  have  dulled  the  desire  for  diagnostic  precision. 
That  phase  has  already  nearly  passed. 

The  Existence  of  the  Condition 

From  all  that  precedes  it  seems  to  me  that  the  occurrence 
in  the  adult  of  congenital  stenosis  must  be  accepted  as  an 
established  fact.  From  the  observations  of  Landerer  and 
Maier  and  from  the  experience  of  Maylard  it  might  even 
be  predicted  that,  as  soon  as  attention  is  definitely  directed 
to  the  condition  of  the  pylorus,  cases  of  pyloric  narrowing  will 
be  found  to  be  a  fairly  common  cause  of  intractable  gastric 
symptoms.  To  again  quote  Maylard :  "  There  exists  a 
considerable  class  of  patients  in  young  adult  life  who  owe 
their  chronic  gastric  trouble  to  a  congenital  narrowness  of 
the  pyloric  orifice."  That  both  the  simple  and  the  hyper- 
trophic forms  will  be  found  also  seems  to  be  probable. 

Three  Cases 

As  a  contribution  to  the  diagnosis  of  congenital  simple 
stenosis  of  the  pylorus  I  submit  the  following  three  cases 
which  had  fallen  into  my  hands  when  this  chapter  was  written. 

Case  14. — Thomas  C,  aged  34,  married,  was  admitted  to 
the  Edinburgh  Royal  Infirmary  on  the  28th  August,  1906.  He 
complained  of  vomiting  and  pain  in  the  abdomen,  and  stated 
that  he  had  been  very  bad  for  the  preceding  six  weeks.  On 
going  into  his  history  it  was  ascertained  that  he  had  been 
troubled  with  his  stomach  for  fifteen  years,  that  is,  since  he 


ILLUSTRATIVE   CASES  105 

was  a  youth  of  19  years.  The  general  description  of  his 
symptoms  was  that  he  had  discomfort,  fullness,  and  heaviness 
in  the  stomach,  coming  on  usually  about  an  hour  after  food. 
The  discomfort  was  sometimes  followed  by  and  relieved  by 
vomiting.  Sometimes  the  vomiting  was  at  night.  The 
vomit  when  copious,  he  thought,  consisted  of  what  he  had 
taken  for  some  days.  The  vomit  had  sometimes  been  dark 
in  colour  and  frothy.  Twelve  years  previously  he  was  treated 
in  the  infirmary  for  dilated  stomach,  and  for  the  same  con- 
dition two  years  later.  Since  that  time  he  had  been  troubled 
off  and  on  with  his  stomach.  For  twelve  months  he  had  had 
comparatively  little  trouble  until  six  weeks  before  admission, 
when  discomfort,  pain,  and  vomiting  came  on.  The  dis- 
comfort and  vomiting  became  very  severe,  and,  he  was 
confident,  worse  than  ever  before  experienced.  He  had  lost 
flesh  and,  of  course,  weight.  Constipation  had  been  extreme, 
the  bowels  only  moving  once  a  week  if  left  to  themselves. 
There  was  no  history  of  melaena,  nor  of  vomiting  recently 
poured  out  blood.  The  patient  had  a  fresh  complexion, 
but  was  very  lean.  The  stomach  was  greatly  dilated  ;  the 
fundus  was  at  the  level  of  the  fifth  rib,  and  the  lower  border 
below  the  level  of  the  umbilicus.  The  lesser  curve  was 
lowered  in  position,  while  the  pylorus  was  high  up  under  the 
liver  edge.  He  on  several  occasions  vomited  as  much  as 
three  pints,  and  as  much  had  been  removed  by  the  stomach 
tube.  The  total  acidity  of  the  gastric  contents  was  high,  and 
there  was  much  free  hydrochloric  acid.  From  the  symptoms 
and  from  the  stomach  dilatation  and  ptosis  there  was  no 
doubt  about  pyloric  obstruction.  The  chemical  examination 
of  the  stomach  contents  excluded  malignant  disease,  and  the 
symptoms  were  not  those  of  gastric  ulcer.  From  the  high 
position  of  the  pylorus  I  inferred  that  it  was  probably  held 
up  by  old  adhesions,  and  that  the  fixity  with  the  addition 
of  ptosis  would  so  kink  the  outlet  as  to  lead  to  obstruction. 
The  patient  had  a  gastro-enterostomy  performed  by  Mr. 
Caird.  At  the  operation  no  adhesions  were  found,  and 
there  was  no  evidence  of  recent  or  of  old  ulceration.  The 
difficulty  at  the  pylorus  was  due  to    an    indurated    and 


io6  THE  STOMACH 

apparently  fibroid  condition  of  the  pyloric  ring.  The  patient 
made  a  speedy  recovery  and  was  entirely  relieved  of  his 
symptoms.  It  never  occurred  to  me  that  the  condition  of 
the  pylorus  found  in  this  patient  might  be  congenital  until 
Mr.  Maylard,  of  Glasgow,  wrote  to  me  on  the  subject, 
pointing  out  that  the  condition  corresponded  with  cases  he 
had  described.  The  suggestion  at  once  appealed  to  my 
judgment,  and  I  was  surprised  it  had  not  instinctively 
occurred  to  me  before. 

Case  15. — James  M.,  aged  42,  married,  was  ad- 
mitted to  the  Edinburgh  Royal  Infirmary  on  the  22nd 
July,  1907.  He  complained  of  vomiting,  constipation, 
giddiness,  and  weakness.  He  stated  that  he  had  lost  much 
flesh  during  the  preceding  fortnight,  and  he  was  so  ill  that 
he  had  been  a  week  in  bed  before  admission.  Careful 
inquiries  into  his  history  elicited  the  fact  that  he  had  suffered 
more  or  less  from  his  stomach  all  his  life.  Even  when 
he  was  a  herd-boy  he  used  often  to  vomit.  The  vomiting 
attacks  came  on  at  intervals  of  a  few  weeks,  at  other  times 
after  an  interval  of  a  few  months.  The  attacks  were 
preceded  by  "  sickness  "  (nausea).  After  vomiting  he  was 
relieved,  but  the  vomiting  might  continue  for  some  days, 
but  after  that  he  would  be  all  right  again  for  a  while.  When 
asked  about  the  character  of  the  vomit,  he  said  that  he 
"  always  minds  that  it  was  very,  very  sour."  At  that  time 
his  food  was  the  same  as  his  brothers  and  sisters  had,  and 
they  did  not  suffer  as  he  did.  These  attacks  of  stomach 
disorder  had  recurred  aU  through  life,  and  it  was  only  by 
great  care  as  to  his  feeding  that  he  was  able  to  avoid  their 
more  frequent  occurrence.  He  usually  breakfasted  at  g  a.m., 
and  could  not  take  another  meal  until  2,  3,  or  4  p.m.  His 
afternoon  meal  commonly  consisted  of  rice-soup  made 
with  mutton,  some  of  the  mutton  being  cut  up  finely  and 
put  into  it ;  or  of  fish  or  tripe  with  .bread.  He  gave  up 
taking  potatoes  and  all  other  vegetables  years  ago,  as  they 
"  always  came  up."  He  drank  a  good  deal  of  skimmed 
milk  and  buttermUk.  His  symptoms  had  been  severe 
since  the  middle  of  June ;   they  were  of  the  same  type  as 


ILLUSTRATIVE  CASES  107 

formerly,  but  were  more  persistent,  and  he  could  not  depend 
on  any  meal  staying  down.  The  stomach  showed  dilatation 
and  ptosis  ;  the  greater  curve  was  considerably  below  the 
level  of  the  umbilicus,  while  the  lesser  curve  reached  the 
level  of  the  umbilicus.  The  pylorus  was  in  the  right  hypo- 
chondrium,  not  far  from  the  costal  margin ;  there  was  no 
thickening.  Handling  the  abdomen  set  up  visible  gastric 
peristalsis.  The  gastric  contents  showed  abundant  free 
hydrochloric  acid.  The  diagnosis  in  this  case  seemed  to  me 
to  be  perfectly  clear,  and  I  strongly  advised  the  patient 
to  submit  to  operation.  A  gastro-enterostomy  was  performed 
by  Mr.  Dowden.  There  was  no  evidence  of  recent  or  cica- 
trized ulcer ;  the  pylorus  had  to  my  eye  much  the  same 
appearance  as  the  former  one,  and  Mr.  Dowden  could  only 
put  the  tip  of  a  finger  into,  not  through,  it.  This  patient 
also  made  an  excellent  recovery. 

Case  16. — Mrs.  H.,  aged  51,  was  admitted  to  the  Edin- 
burgh Royal  Infirmary  on  the  25th  October,  1907.  She 
was  a  small,  spare,  ill-nourished  woman.  Her  complaints 
were  referred  to  the  stomach.  She  had  suffered  all  her 
life  from  indigestion,  but  for  the  past  four  years  her  symptoms 
had  been  more  pronounced.  In  fact,  during  that  period 
her  medical  history  was  a  varied  one,  although  gastric 
symptoms,  as  pain  and  vomiting,  appear  to  have  pre- 
dominated. She  had  never  been  able  to  eat  vegetables  ; 
there  was  a  history  of  having  vomited  material  like  coffee 
grounds  shortly  before  admission  to  the  infirmary.  On 
examination  the  stomach  showed  dilatation  and  ptosis, 
both  curves  being  displaced  downwards,  the  greater  one 
reaching  to  considerably  below  the  level  of  the  umbilicus. 
There  was  often  visible  gastric  peristalsis.  There  was  no 
thickening  of  the  pylorus.  The  gastric  contents  contained 
no  free  hydrochloric  acid.  From  the  dilatation,  ptosis, 
and  peristaltic  movements  there  was  no  doubt  as  to  the 
existence  of  pyloric  difficulty,  but  without  pyloric  thickening. 
The  symptoms  were  not  those  of  gastric  ulcer.  The  absence 
of  thickening  at  the  pylorus  led  me  to  negative  malignant 
disease  notwithstanding  the  absence  of  free  hydrochloric 


io8  THE  STOMACH 

acid.     In  fact,  the  symptoms  seemed  to  me  to  be  due  to 
the  retention  of  stomach  contents  ;    and  in  view  of  the 
lifelong  history  of  indigestion  and  the  need  of  extreme  care 
with  regard  to  food  and  great  moderation  in  the  quantity 
taken,  I  looked  upon  this  case  as  another  example  of  conge- 
nital stenosis.     I  advised  this  patient  to  submit  to  operation. 
Mr.  Hodsdon  operated.   The  case  was,  however,  an  unlooked- 
for  disappointment.     The  condition  at  the  pylorus  was  as 
I  had  judged  it  to  be  ;  but  there  was  in  addition  a  malignant 
growth  high  up  at  the  fundus  which  could  not  be  removed. 
A  gastro-enterostomy  nevertheless  was  performed  and  gave 
the  patient   complete   relief   from   her  gastric   symptoms. 
She  made  an  excellent  recovery,     but  the  operation  was 
foUowed  by  that   curious  feeling    of  "  having  no   mind  " 
which  is  one  of  the  occasional  and  mysterious  sequelae  of 
such  operations.     There  was  no  constant  pain,  no  pain  on 
the  ingestion  of  food,  no  difficulty  of  deglutition,  no  mass 
to  be  felt,  to  guide  us  to  the  suspicion  of  malignant  growth 
at   the   fundus.      The   absence   of    free   hydrochloric   acid 
suggested  malignancy,  but  being  satisfied  that  the  pylorus 
was  not  malignant  the  idea  was  set  aside.     I  concluded 
that  the  absence  of  free  HCl  was  an  individual  pecuHarity 
which  is  not  rare. 

I  heard  of  this  patient  in  the  beginning  of  June,  1908. 
There  had  been  no  return  of  the  gastric  symptoms  and  no 
further  signs  of  malignancy.  The  mental  condition  had  not 
improved. 

Diagnosis 

The  diagnosis  may  be  briefly  summed  up  under  the 
following  heads  : 

History. — ^There  is  a  long  history  of  stomach  trouble,  or 
of  such  digestive  difficulties  that  the  patient  has  learnt  to 
be  very  careful  as  to  the  character  and  the  quantity  of 
food  taken,  and  to  allow  a  sufficient  number  of  hours  to 
separate  meals.  On  the  intelligence  with  which  diet  has 
been  regulated  depends  the  further  history.  There  may 
be  a  history  of  supposed  bilious  attacks  dating  back  into 


DIAGNOSIS  109 

childliood.  In  Case  15  the  patient  as  a  boy  had  at  varying 
intervals  of  time  attacks  of  vomiting,  which  lasted  for  a 
day  or  two.  He  had  had  these  when  his  feeding  was  his 
share  of  the  food  provided  for  the  family,  yet  none  of  his 
brothers  or  sisters  had  similar  attacks.  As  he  grew  to 
manhood  he  had  learnt  great  abstemiousness  in  eating  and 
drinking,  and  thus  saved  himself  from  a  frequent  repeti- 
tion of  acute  digestive  disorder.  In  Case  16  the  patient 
had  similarly  learnt  by  experience  how  to  regulate  her 
diet.  In  Case  14,  where  possibly  the  stenosis  may  have  been 
less  pronounced,  there  was  a  definite  history  of  preceding 
attacks  of  severe  digestive  disorder  with  stomach  dilata- 
tion. In  all  three  patients  previous  attacks  had  been  over- 
come by  ordinary  dietetic  and  medicinal  means ;  they 
came  to  hospital  because  ordinary  means  had  failed,  and 
ordinary  means  failed  in  our  hands  also. 

Symptoms. — ^The  symptoms  are  the  symptoms  of 
stomach  dilatation  or  of  gastric  dyspepsia,  vomiting  only 
occurring  in  the  more  severe  attacks.  The  attacks  of 
stomach  disorder  tend  to  become  intensified  as  they  are 
repeated ;  and  as  Mayo  Robson  has  observed,  something 
happens,  often  not  till  life  is  fairly  advanced,  which  brings 
out  the  pyloric  difficulty  and  leads  to  all  the  symptoms  of 
pronounced  pyloric  obstruction. 

Physical  Examination. — At  the  stage  when  these  cases 
are  likely  to  come  to  hospital,  stomach  dilatation  is  easily 
made  out  on  physical  examination.  In  two  of  my  three  cases 
gastric  peristalsis  could  be  induced.  In  Case  14  the  dilata- 
tion and  gastric  atony  were  too  pronounced  to  allow  of  this 
sign  being  elicited.  When  gastric  peristalsis  can  be  induced 
the  pyloric  end  of  the  stomach  also  contracts  and  is  easily 
located.  In  my  three  cases  there  was  no  permanent — that 
is  to  say,  continuous — pyloric  thickening.  The  cases 
being  examples  of  the  simple  form  accounts  for  the  absence 
of  this  sign  ;  whereas  in  the  combined  or  hypertrophic 
form  there  is  permanent  thickening,  although  the  degree 
of  thickening  will  vary  from  time  to  time.  The  absence 
of    continuous    pyloric    thickening    is    a    most    important 


no  THE   STOMACH 

diagnostic  point,  but  the  negation,  of  course,  assumes  that 
the  pylorus  can  be  located  through  the  parietes. 

Pyloric  Spasm  or  Cramp. — ^This  as  a  physical  sign  re- 
quires a  Httle  special  reference  made  to  it.  Kussmaul  ^ 
appears  to  have  been  the  first  to  draw  attention  to  it.  It  is 
recognized  by  Ewald,  Hemmeter,  Van  Valzah  and  Nisbet, 
and  Boas.  It  is  a  condition  that  I  knew  clinically  long 
before  I  knew  that  Kussmaul  had  noted  it.  When  spasm 
occurs,  the  pylorus  hardens  and  thickens  ;  when  spasm 
relaxes,  the  pylorus  softens.  The  two  phases  can  usually  be 
easily  followed  by  the  hand  placed  over  the  pylorus,  as  the 
patients  are  lean  with  a  lax  abdominal  wall.  The  spasm 
can  be  caused  by  the  irritation  of  the  stomach  contents,  by 
structural  lesion  at  or  near  the  pylorus,  or  even  by  nervous 
disorder.  Spasm  occurs  both  with  and  without  permanent 
hj^pertrophic  or  hyperplastic  thickening  of  muscular  and 
fibrous  tissue.  Such  permanent  thickening  is  also  no 
necessary  accompaniment  of  pyloric  narrowing  ;  in  fact,  in 
my  three  cases  there  was  no  thickening,  and  reference  has 
been  made  to  similar  observations  by  others.  When  spasm 
is  present  there  is  thickening,  and  in  this  way  spasm  often 
enables  us  to  locate  with  certainty  the  position  of  the 
pylorus,  while  the  knowledge  thus  gained  of  its  position 
may  enable  us  to  definitely  determine  after  spasm  has 
relaxed  whether  structural  thickening  has  remained. 
When  structural  thickening  remains,  the  question  of  its 
cause  remains  to  be  decided. 

Chemical  Examination  of  Gastric  Contents. — The  chemical 
examination  of  the  stomach  contents,  especially  the 
determination  of  the  presence  or  absence  of  free  hydro- 
chloric acid,  should,  of  course,  never  be  omitted,  for  the 
result  materially  influences  the  formation  of  an  opinion. 

Summary. — ^The  diagnosis  in  the  case  of  simple  stenosis 
is  determined  by  the  existence  of  pyloric  difficulty,  the 
character  and  duration  of  the  history,  the  absence  of  per- 
manent pyloric  thickening,  the  presence  of  free  hydro- 
chloric  acid   in   the   stomach   contents,    the   exclusion   of 

^  Kussmaul,  Dent.  Arch.  f.  kJin.  Med.,  1869,  Bd.  vi.  p.  455. 


THE   CLINICAL   PATHOLOGY  in 

ulcer,  of  malignancy  at  the  pylorus,  and  of  a  history  that 
would  fit  in  with  cicatrix  from  previous  ulceration.  \Mien 
there  is  permanent  thickening  the  benign  causes,  when  we 
exclude  ulcer,  are  congenital  hypertrophic  stenosis,  and 
cicatrix  from  healed  ulcer.  The  field  for  differential 
diagnosis  can  thus  be  greatly  circumscribed  and  simplified. 
In  fact,  once  the  possibility  of  congenital  stenosis  occurring 
in  the  adult  enters  the  clinical  field  of  vision,  it  will,  I 
think,  be  found  to  be  quite  within  the  differential 
diagnostic  skill  of  the  physician. 

Treatment 

The  treatment  might  be  summed  up  in  the  words 
of  Lambert  and  Foster,  i  when  discussing  benign  stenosis 
of  the  pylorus,  namely  :  (i)  Control  excessive  secretions, 
(2)  reduce  pyloric  irritability,  and  (3)  increase  the  muscular 
activity  of  the  stomach  wall.  Space  does  not  permit  of 
these  principles  being  elaborated  here.  \Mien  dietetic 
and  medicinal  measures  are  no  longer  sufficient  to  enable 
a  patient  to  nourish  himself,  the  physician  can,  fortunateh' 
with  confidence,  advise  the  patient  to  submit  to  surgical 
operation. 

The  Clinical  Pathology 

I  have  not  had  the  opportunity  of  examining  post 
mortem  the  character  of  the  anatomical  change  at 
the  pylorus  in  simple  stenosis.  The  changes  in  both 
the  simple  and  the  hypertrophic  form  have,  however, 
been  dealt  with  by  Maier  and  Maylard.  In  the  three 
cases  which  have  been  in  my  hands  I  have  only  seen  the 
pylorus  when  it  was  exposed  at  the  time  of  the  operation 
and  when  the  surgeon  was  satisfied  as  to  the  smallness  of 
the  opening  and,  at  the  same  time,  of  the  absence  of  ulcer, 
new  growth,  or  cicatrix  to  account  for  it.  Under  these 
circumstances,  I  fail  to  see  what  view  the  clinical  patho- 
logist   can    hold    but    that    the    narrowing   or    stenosis    is 

^  Loc.  cit. 


112  THE  STOMACH 

congenital.  There  is,  so  far  as  I  know,  no  pathological 
process  which  produces  this  kind  of  change,  while  I  am 
told  that  a  more  or  less  corresponding  congenital  condition 
occurs  at  the  internal  os  of  the  uterine  cervix,  and  a  con- 
genital tightness  of  the  prepuce  is  common.  That  the 
condition  may,  in  some  instances,  be  the  true  cause  of  the 
attacks  of  indigestion  or  dyspepsia  seen  in  young  people 
has  to  be  kept  in  mind,  for  until  the  possibility  of  occur- 
rence is  present  to  the  mind  it  cannot  be  diagnosed.  In 
young  or  later  adult  life  symptoms  are  more  likely  to 
become  pronounced,  for  it  is  a  common  experience  to  find 
digestive  disturbances  emerging  during  this  period.  It 
must  also  be  acknowledged  that,  if  congenital  narrowing 
be  present,  gastric  catarrh,  hyperchlorhydria,  or  pyloric 
spasm  \n\l  all  tend  to  present  exaggerated  symptoms. 
When,  therefore,  any  one  of  these  conditions  is  present,  the 
definiteness  of  pyloric  difficulty  may  be  a  surer  guide  to  the 
existence  of  the  congenital  defect  than  we  as  yet  know. 
Another  factor  which  Maylard  lays  stress  on,  probably 
rightly,  is  that  any  condition  which  weakens  the  muscular 
coat  of  the  stomach,  such  as  anaemia  or  general  debility, 
will  bring  out  symptoms  of  digestive  trouble,  owing  to  the 
pyloric  narrowing  effectively  preventing  the  passage  of  the 
gastric  contents  under  the  lowered  pressure  of  weak 
stomach  contraction.  There  are  thus  several  explanations 
to  account  for  the  symptoms  of  congenital  stenosis  first 
appearing  prominently  in  adult  life,  or  at  least  assuming 
such  prominence  as  to  send  the  sufferer  to  seek  medical 
help. 

Further  Remarks  on  Congenital  Stenosis 

Since  the  preceding  pages  were  written  experience  has 
increased  and  a  wider  view  of  the  relations  of  this  condition 
has  been  obtained.  The  condition  does  not  appear  to  be 
commonly  recognized,  yet  it  is  possible  that  many  persons 
are  the  victims  of  this  narrowing.  Such  persons  early 
learn  to  eat  sparingly  and  carefully,  as  experience  teaches 
them  that  indulgence  is  followed  by  discomfort.     Another 


FURTHER  CASES   AND   REMARKS  113 

interesting  and  important  point  in  some  of  these  cases  is, 
that  pronounced  symptoms  may  not  appear  until  middle 
life  is  reached,  and  that  as  life  advances  the  symptoms 
become  more  pronounced.  The  explanation  seems  to  be 
that  under  conditions  of  physical  or  mental  stress,  or  of 
both,  the  involuntary  musculature  of  the  stomach  is 
weakened  and  not  so  able  to  overcome  the  congenital 
defect.  This  leads,  of  course,  to  atonic  dilatation  with 
undue  retention  of  food  and  consequent  discomfort.  In 
other  cases  disordered  secretion,  particularly  in  the  direction 
of  over-secretion  of  acid,  supervenes,  and,  to  the  factor  of 
stenosis,  pyloric  spasm  is  added,  leading  to  still  longer 
retention  and  to  still  further  dilatation.  I  have  recentl}^ 
heard  of  a  case  of  this  kind  successfully  operated  on, 
although  the  patient  was  over  sixty  years  of  age. 

This  is  in  keeping  with  our  experience  of  other  gastric 
disorders  in  younger  people.  In  hyperchlorhydria,  for 
instance,  the  typical  symptom  in  older  persons,  of  recurring 
pain  does  not  in  early  life  get  beyond  the  stage  of  discomfort, 
I  recently  saw  a  girl,  twelve  years  of  age,  at  the  suggestion 
of  Sir  Henry  Dalziel  of  Glasgow,  as  there  was  a  question 
about  the  state  of  the  appendix.  That  structure  was  giving 
rise  to  anxiety,  for  there  had  been  abdominal  discomfort,  and 
the  caecal  region  was  tender,  so  its  removal  was  recommended. 
An  X-ray  plate  showed  a  large  stomach  for  a  child,  and 
I  suggested  that  it  was  congenital.  The  appendix  was 
removed  by  Sir  Henry  Dalziel,  and  he  informed  me  that 
in  the  family  more  than  one  member  had  a  congenitally 
narrow  pylorus.  Yet  this  child  had  so  far  not  shown 
gastric  symptoms. 

Two  additional  cases  may  be  given,  as  they  illustrate  the 
condition  as  present  in  youth  and  in  middle  age. 

Narrow  Pv'lorus:  Ulcer  and  Stenosis 
at  duodeno-jejunal  junction 

Case  17. — C.  L.,  a  girl  of  15  years,  was  admitted  to 
the  Royal  Infirmary  on  the  9th  November,  1908.  She 
was  under-developed  and  very  thin.      Six  months  before 

8 


114  THE  STOMACH 

she  had  suffered  from  diarrhoea  for  two  months,  from  which 
she  had  to  a  great  extent  recovered.  After  this  she  developed 
pain  over  the  stomach  and  vomiting.  Pain  was  alwaj^s 
present  but  varied  in  intensity,  sometimes  reUeved  by  food, 
sometimes  made  worse.  Vomiting  also  occurred  at  irregular 
times  and  once  or  twice  daily.  On  examination  of  the 
abdomen  its  wall  was  held  tense,  but  no  pain  was  elicited  by 
such  palpation  as  was  practicable.  Stomach  splashing 
was  easily  elicited  ;  the  organ  was  large,  the  right  border 
being  at  the  right  costal  edge.  The  patient  was  sent  to 
me  by  one  of  my  surgical  coUeagues  for  observation  and  with 
a  view  to  her  general  condition  being  improved.  We  did 
all  we  could  for  her  by  careful  dieting  and  medication  ; 
the  stomach  contents  removed  on  several  occasions  by  means 
of  the  tube  showed  no  free  acid.  She  became  steadily 
worse  and  died  on  the  15th  December.  Her  condition 
was  discussed  at  the  clinic  and  the  conclusion  was  arrived 
at  that  there  was  probably  congenital  pyloric  stenosis,  with 
something  in  addition  which  did  not  appear  to  be  ulcer 
near  the  pylorus.  There  was  no  doubt  that  there  was 
extreme  difficulty  in  passing  on  the  stomach  contents,  that 
there  was  an  absence  of  hydrochloric  acid,  that  there  was 
no  palpable  thickening  of  the  pylorus,  and  that  stomach 
peristalsis  of  fair  strength  was  present,  for  it  could  be  seen 
and  felt.  This  case  occurred  before  X-ray  examination 
with  bismuth  had  attained  the  useful  position  it  has  now 
attained,  so  that  method  of  examination  was  not  available. 
Had  the  girl  lived  longer  the  abdomen  would  no  doubt 
have  been  opened  with  a  view  to  gastro-enterostomy.  The 
post-mortem  examination  showed  an  enlarged  stomach  with 
a  distinct  band  of  thickening  at  the  pylorus,  composed 
principally  of  muscular  tissue.  There  was  marked  dilatation 
of  the  second  and  third  parts  of  the  duodenum.  There  was 
an  ulcer  surrounding  the  gut  at  the  duodeno-jejunal  junction 
which  encroached  so  much  on  the  lumen  of  the  gut  that 
only  a  No.  6  catheter  could  be  passed  through  the  obstruction. 
There  were  old  and  some  recent  tuberculous  lesions  in  the 
abdomen   and   old   caseous   changes   in   the   thorax.     This 


NARROW  PYLORUS  115 

case  is  briefly  recorded  here  on  account  of .  its  unusual 
character,  and  as  an  illustration  of  the  advance  which  has 
been  made  in  methods  of  examination  within  the  past 
twelve  years. 

Indefinite  SvMPtoMS :  Narrow  Pylorus  :  Pyloro- 
plasty :  Recovery 

Case  18. — Annie  D.,  aged  46,  was  admitted  to  the 
Royal  Infirmary  on  the  24th  February,  1911.  The 
complaint  was  "  pain  in  stomach."  Eight  weeks  before 
admission  she  began  to  suffer  from  burning  pain  in  the 
left  hypochondrium  which  extended  over  the  left  side 
of  the  chest.  The  pain  was  not  severe,  but  was  always 
present  and  was  not  influenced  by  taking  food.  After 
about  a  week  the  pain  became  more  severe,  coming  on  an 
hour  after  food  and  lasting  for  two  and  a  half  hours.  She 
was  put  on  light  diet,  but  this  did  not  lessen  the  pain.  The 
pain  often  prevented  her  sleeping.  She  came  to  Edinburgh 
and  was  admitted  to  the  Royal  Infirmary.  She  did  not 
suffer  from  flatulence  or  acid  eructations,  and  there  had 
been  no  vomiting.  The  bowels  moved  daily  and  easily. 
She  had  lost  weight.  Twenty  years  before,  she  had  suffered 
much  from  indigestion,  pain  coming  on  immediately  after  food 
and  being  often  accompanied  by  vomiting.  She  was  treated 
at  that  time  for  "  gastric  ulcer,"  being  put  on  milk  diet 
and  kept  in  bed.  In  three  weeks  she  completely  recovered. 
From  that  time  she  had  occasionally  experienced  discomfort 
after  food,  but  not  pain.  On  examination  of  the  abdomen 
the  fundus  of  the  stomach  was  found  to  be  somewhat 
enlarged,  and  there  was  slight  tenderness  in  the  right  hypo- 
chondrium. All  her  organs  were  sound,  the  urine  presented 
no  important  change,  the  blood  showed  a  moderate  anaemia. 
The  gastric  contents  removed  on  two  occasions  showed  much 
free  hydrochloric  acid.  During  the  seven  weeks  she  was 
in  my  ward  she  was  dieted  with  great  care,  first  with  milk, 
then  with  egg  and  milk,  then  with  gruel  and  milk,  arrow- 
root and  milk,  and  occasionally  with  fish.     Belladonna  and 


ii6  THE   STOMACH 

an  alkali  were  given  and  the  colon  was  washed  out.  Later 
small  doses  of  morphine  were  added  to  the  belladonna. 
All  these  measures  had  no  beneficial  effect  on  the  pain. 
It  persisted,  although  it  varied  in  intensity,  and  sometimes 
prevented  her  sleeping.  The  feeling  of  weight  remained 
stationary.  ]\Iy  surgical  colleague,  Mr.  Miles,  saw  the  patient 
and  it  was  decided  to  open  the  abdomen.  The  operation 
was  performed  on  the  4th  April.  There  was  no  evidence 
of  present  or  past  ulceration,  but  the  pyloric  outlet  was 
very  small.  A  pyloroplasty  was  done.  The  patient  made 
an  excellent  recovery  and  was  entirely  cured  and  had 
remained  well  when  last  heard  of. 

Treatment. — Individuals  with  pyloric  narrowing  who 
have  succeeded  in  keeping  gastric  discomfort  in  abeyance, 
do  not  come  under  the  notice  of  the  physician,  and  only 
incidentally  under  the  notice  of  the  general  practitioner  ; 
yet  it  may  be  assumed  there  are  many  such  persons.  When 
a  case  of  congenital  stenosis  in  early,  middle,  or  later  life 
comes  under  observation  the  symptoms  which  have  emerged 
are  due  either  to  the  supervention  of  a  failure  of  muscle 
compensation  or  to  an  attack  of  hyperchlorhydria.  In  the 
former  case  the  treatment  ought  to  be  directed  to  facilitating 
and  hastening  gastric  digestion,  by  supplying,  not  only 
suitable  food,  but  ensuring  that  aU  food  is  either  minced  or 
made  into  pulp  in  the  mouth  before  being  swallowed.  And 
in  the  second  place  by  the  administration  of  such  tonics  as 
may  be  indicated,  strychnine  being  the  best,  and,  when 
necessary,  relief  from  the  physical  or  mental  strain  which 
may  have  contributed  to  the  break  down  in  compensation. 
WTien,  on  the  other  hand,  the  symptoms  result  from  too  free 
secretion  of  hydrochloric  acid,  treatment  must  be  directed 
to  checking  it.  If  these  methods  aU  fail,  recourse  must  be 
had  to  surgical  measures,  and  this  can  now  be  advised  with 
the  utmost  confidence.  At  the  same  time  it  must  be  in- 
sisted on,  that  the  presence  of  congenital  narrowing  cannot 
be  taken  as  necessarily  requiring  surgical  interposition,  and 
that  it  is  the  duty  of  the  physician  to  determine  the  cause 
of  the  emergence  of  symptoms,  and  then  to  endeavour  to 
remove  them  by  dietetic  and  medicinal  measures. 


CHAPTER  XI 

GASTRIC   ULCER 

Simple  Gastric  Ulcer  may  for  clinical  purposes  be  divided 
into  two  groups,  namely,  acute  and  chronic,  or  recent  and 
long-standing.  The  group  in  which  the  individual  case  is 
placed  will  to  a  very  important  degree  influence  the  prog- 
nosis and  determine  the  measures  to  be  taken  for  the  removal 
of  the  symptoms  and  the  repair  of  the  ulcer.  It  will  be 
found  to  carry  much  the  same  significance  as  is  attached  to 
the  terms  "  acute  "  and  "  chronic  "  when  applied  to  an  ulcer 
of  the  leg. 

Acute  or  Recent  Gastric  Ulcer 

Pathogeny. — ^The  acute  gastric  ulcer  presents  a  punched- 
out  appearance,  with  but  little  if  an5'  appreciable  infiltration 
of  its  floor  or  edges.  There  is  a  larger  area  of  mucous 
membrane  destroyed  than  of  the  underlying  coats,  which 
gives  its  section  a  terraced  appearance.  The  exact  etiology 
is  still  a  subject  of  speculation  ;  it  does,  however,  appear 
as  if  from  one  cause  or  another  there  must  be,  to  begin 
with,  a  localized  area  of  greatly  lowered  tissue  vitality, 
or  even  of  necrosis,  from  interference  with,  or  complete 
arrest  of,  the  blood  circulation  at  the  affected  spot ;  and 
that,  as  a  result,  the  devitalized  or  necrosed  tissue  is  rapidly 
digested  by  the  gastric  juice,  so  that  a  clean-cut  ulcer  is 
left. 

Preceding  Conditions. — In  the  great  majority  of  cases 
ulcer  is  preceded  by  definite  symptoms  of  gastric  and 
digestive  disorder.     In  young  women,  in  whom  gastric  ulcer 

"7 


ii8  THE  STOMACH 

is  common,  the  stage  of  ulcer  is  often  preceded  not  only 
by  a  history  of  indigestion,  but  also  of  chlorosis.  In  men 
ulcer  is  also  preceded  by  a  long  history  of  indigestion  or  of 
dj^spepsia.  Even  the  form  the  dyspepsia  assumes  is  known 
to  be  the  acid  form,  in  which  heart-burn,  water-brash,  acid 
eructations,  and  flatulence  are  prominent  phenomena.  In 
fact,  gastric  ulcer  has  come  to  be  so  closely  associated  with 
hyperacidity  that  the  acidity  has  come  to  be  looked  upon 
as  having  an  etiological  significance,  although  the  precise 
part  it  takes  in  determining  ulcer  formation  is  not  known. 
In  men  it  appears  as  if  hyperchlorhydria  were  frequently 
the  precursor  of  gastric  ulcer.  This  gains  support  from  the 
contentions  which  have  emanated  from  certain  quarters, 
that  aU  cases  of  so-caUed  hyperchlorhydria  are  really  cases 
either  of  gastric  or  of  duodenal  ulcer.  This  contention  is 
based  upon  the  failure  to  recognize  the  existence  of  such  a 
condition  as  hyperchlorhydria  ;  but  the  diagnosis  of  this 
form  of  altered  function  has  been  so  fully  discussed  in  an 
earlier  chapter,  that  it  is  unnecessary  to  deal  with  it  again 
here,  while  the  contention  is  utilized  to  support  our  own 
experience,  that  hyperchlorhydria  may  be  followed  by,  or 
even  lead  to,  ulcer. 

Position  of  Ulcer. — ^The  position  of  ulcer  may  be  at 
almost  any  point  of  the  gastric  wall,  although  the  frequency 
with  which  it  is  found  is  not  the  same  at  all  points.  It  is 
more  common  in  the  pyloric  half  of  the  organ,  and  on  the 
lesser  rather  than  the  greater  curve.  It  may,  however, 
be  close  to  the  cardiac  opening.  The  symptoms  are  modified 
and  influenced  by  the  position  of  the  ulcer,  as  might  be 
anticipated  ;  and  as  pain  is  the  leading  symptom  in  all 
cases  it  is  this  symptom  which  is  mainly  influenced.  The 
site  of  the  pain  and  the  time  it  comes  on  after  taking  food 
are  guides  to  the  position.  The  nearer  the  ulcer  is  to  the 
pylorus  the  longer  the  interval  between  taking  food  and  the 
onset  of  pain  ;  but  it  is  not  usually  longer  than  half  an  hour. 
It  often  comes  on  immediately  after  taking  food. 

Symptoms. — In  most  cases  of  gastric  ulcer  there  is  a 
history  of  longer  or  shorter  duration  of  symptoms  of  gastric 


ACUTE   OR   RECENT  GASTRIC   ULCER       119 

disorder.  These  symptoms  are  discomfort  coming  on  some 
time  after  taking  food  ;  flatulence  with  eructation  of  air  ; 
heart-burn  ;  pyrosis,  or  the  eructation  of  mouthfuls  of  acid 
material ;  perhaps  pain,  coming  on  an  hour  or  two  after 
food  has  been  taken ;  occasionally  vomiting.  There  is 
usually  a  dehnite  history  of  constipation  with  the  bowels 
moving  only  when  purgative  medicine  has  been  taken  ;  or 
moving  without  such  assistance,  but  scantily  and  quite 
inefficiently. 

General  symptoms  are  present,  as  well  as  local  symptoms, 
such  as  weakness  and  inability  for  exertion  or  even  for 
ordinary  domestic  duties.     Languor  and  apathy  are  common. 

All  these  symptoms  may  have  lasted  for  months,  indicating 
disturbance  of  gastric  function. 

When  ulcer  has  formed  the  main  symptom  is  fain 
referred  to  the  stomach,  not  infrequently  going  through  to 
the  back  in  the  lumbar  region.  It  comes  on  immediately 
after  or  soon  after  food  is  taken.  It  continues  until  all  food 
has  left  the  stomach,  and  it  returns  when  food  is  again  taken. 
This  sequence  is  so  definite,  even  to  the  least  observant  of 
persons,  that  as  little  food  is  taken  as  possible,  with  the 
inevitable  result  of  lowered  health  and  strength  and  the 
development  of  ancemia.  There  is  almost  always  pro- 
nounced constipation,  an  efficient  motion  being  only  obtained 
by  means  of  some  laxative  or  purgative  medicine.  There 
may  be  hcematemesis,  the  vomiting  of  recently  poured-out 
blood,  or  of  material  resembling  coffee  grounds  or  hare  soup, 
and  consisting  of  blood  which  has  lain  in  the  stomach  for 
some  time  and  has  been  acted  upon  by  the  gastric  secretion. 
When  there  has  been  a  large  haemorrhage  part  of  the  blood 
passes  into  the  duodenum,  and  when  passed  per  anum  is 
black  in  colour,  and  known  as  melcena.  The  amount  of 
bleeding  varies  greatly,  it  may  be  so  profuse,  or  repeated  so 
frequently,  as  to  endanger  life. 

Perforation. — The  ulcer  may  be  of  the  acute  perforating 
type,  when  all  the  coats  of  the  stomach  wall  are  involved 
in  the  morbid  process.  This  is  probably  the  more  common 
history  of  perforation  ;  but  perforation  may  occur  in  an  ulcer 


120  THE  STOMACH 

which  has  been  present  for  some  time,  and  even  in  an  ulcer 
of  long  duration.  The  diagnosis  of  perforation  is  difhcult 
in  some  instances,  especially  if  the  perforation  be  small,  and 
be  so  situated  that  there  has  been  little  escape  of  gastric 
contents.  The  guiding  symptoms  are  sudden  pain,  collapse, 
and  acute  tenderness  over  the  whole  abdomen.  It  is  doubt- 
ful if  any  other  condition  in  the  abdomen  produces  these 
three  phenomena  so  suddenly.  No  doubt  perforation  may 
occur  elsewhere,  but  with  the  pain  referred  to  the  upper 
half  of  the  abdomen  the  perforation  is  either  in  the  stomach 
or  duodenum, — ^which  it  is,  is  of  merely  academic  interest ; 
whichever  it  is,  prompt  action  is  required. 

Reservations  and  Wrong  Diagnoses. — A  reservation  has 
to  be  made  when  gastric  ulcer  is  spoken  of  or  thought  of. 
The  mental  picture  is,  or  tends  to  be,  of  the  full-blown  and 
classical  acute  perforating  type.  It  is  necessary,  however, 
to  think  of  the  mucous  membrane  of  the  stomach  presenting 
abrasions  or  excoriations,  without  extension  into  the  deeper 
coats,  with  little  risk  of  such  extension,  and  therefore  with 
no  risk  of  perforation.  That  some  bleeding  occurs  not  only 
from  such  an  abrasion,  but  even  from  a  limited  area  of 
congested  vessels,  must  also  be  accepted  as  reasonable  and 
requires  a  further  reservation.  The  lurid  picture  evoked 
by  the  diagnosis  of  "  gastric  ulcer  and  haematemesis  "  is 
much  modified  if  it  can  reasonably  be  thought  of  as  excoria- 
tion or  congestion  of  the  gastric  mucosa  with  some  blood 
leakage,  and  this  it  must  often  be. 

This  explanation  is  offered  to  explain  the  large  number 
of  cases  of  wrong  diagnosis  which  were  admitted  to  m}^  wards 
in  the  Royal  Infirmary.  WTien  a  bed  was  available  I  never 
refused  to  admit  a  case  which  was  said  to  be  gastric  ulcer 
with  slight  haematemesis,  or  indeed  entirel}^  without  a  history 
of  haematemesis.  A  great  many  cases  of  this  description 
passed  through  the  female  ward.  They  were  carefully 
investigated  as  to  history  and  symptoms.  "  Pain  after 
food  "  was  often  reduced  to  occasional  pain,  or  pain  after 
a  fairly  large  meal,  which  might  only  last  for  a  short  time. 
The  history  was  wanting  in  recurrence  of  pain  after  each 


ACUTE   OR  RECENT  GASTRIC  ULCER       121 

meal  and  continuing  until  the  stomach  was  empty.  The 
symptoms  of  gastric  ulcer  were  found  on  careful  investiga- 
tion to  be  wanting,  in  many  cases  in  which  a  history  was 
given  of  hsematemesis.  The  patients  were  often  of  poor 
physique,  often  anaemic  or  chlorotic,  and  there  was  pro- 
nounced constipation.  The  routine  treatment  adopted  for 
them  was  colon  lavage  by  means  of  a  douche  can,  instead 
of  by  an  enema  syringe,  at  intervals  of  three  or  four  hours, 
using  about  30  ounces  at  a  time.  The  diet  was  in  some  cases 
restricted  at  hrst  to  milk  gruel  made  with  oatmeal,  in  other 
cases  the  ordinary  light  diet  of  the  Infirmary  was  given. 
Most  of  these  cases  got  rapidly  well  and  were  entirely 
relieved  of  gastric  symptoms.  In  a  few  cases  compound 
tincture  of  rhubarb  with  bicarbonate  of  soda  and  chloroform 
water  were  given,  especially  if  the  tongue  were  coated  or 
deeply  furred.  Before  leaving  hospital  the  regular  action 
of  the  bowels  was  attained  by  phenol  phthalein  or  cascara, 
to  which  taraxacum  might  be  added  or  the  three  com- 
bined. 

My  experience  in  Edinburgh  of  this  common  error  in 
diagnosis  corresponds  with  Sir  Berkeley  Moynihan's  in 
Leeds,  the  difference  being  that  the  patients  were  sent  to 
him  as  a  surgeon,  to  me  as  a  physician. 

Gastric  Ulcer  Heals.  —  That  gastric  ulcer  which  has 
not  been  allowed  to  become  chronic  can  and  does  heal,  is 
proved  by  the  presence  of  scars  in  the  stomach  wall.  In- 
teresting experiments  were  recorded  by  Dr.  C.  A.  Bolton, 
in  1910.  He  produced  acute  ulcers  in  guinea-pigs  by 
injecting  gastro-toxin  into  the  stomach  wall,  and  found 
that  the  area  was  rapidly  digested  by  the  gastric  juice.  He 
found  that  the  ulcers  healed,  taking  from  two  to  four  weeks 
to  do  so.  There  can  be  no  reasonable  doubt  that  in  the 
human  subject  a  like  rapid  healing  can  take  place  under 
favourable  conditions. 

Treatment  of  Acute  Gastric  Ulcer.—  In  cases  of  severe 
haemorrhage,  when  the  surgeon  did  not  think  the  patient's 
condition  permitted  operation,  or  when  it  was  decided 
to  wait  and  watch,  the  treatment  adopted  was  the  with- 


122  THE   STOMACH 

holding  of  food  for  a  few  days,  then  beginning  with  small 
quantities  of  diluted  milk  to  which  some  bicarbonate  of 
soda  was  added.  In  recurrence  morphine  and  atropine  were 
given  hypodermically,  and  in  some  cases  chloride  of  calcium 
by  the  rectum  seemed  to  check  the  bleeding.  The  diet  was 
increased  gradually  by  adding  to  the  milk  first  oatmeal 
gruel  and  then  raw  egg  beaten  up.  The  medicines  used 
were  soda  and  belladonna  to  counteract  acidity  and  to 
inhibit  its  too  free  secretion.  If,  in  spite  of  these  measures 
symptoms  of  ulcer  continued,  the  question  of  surgical  inter- 
position was  considered.  Each  case  has  to  be  judged  of 
separately.  In  some  cases  of  severe  haemorrhage  the 
patient's  condition  may  not  contra-indicate  operation,  and 
if  there  has  been  a  history  of  previous  gastric  trouble, 
especially  if  there  is  evidence  of  gastric  dilatation  with  the 
right  border  considerably  to  the  right  of  the  middle  line, 
operation  is  indicated.  If  there  is  a  recurrence  of  evidence 
of  bleeding,  the  indication  is  operation. 

The  following  case  illustrates  what  symptoms  and  signs 
are  present  when  the  question  of  operation  has  definitely 
emerged  in  a  recently  formed  ulcer. 

Hyperchlorhydria  History  for  Ten  Years  :  Recent 
Gastric  Ulcer  with  Pain  and  H^matemesis  : 
Dilated  Stomach  :  Operation 

Case  19. — John  R.,  aged  45,  was  admitted  to  my  ward 
on  the  12th  October,  1914,  complaint  being  "  pain  in  stomach 
and  vomiting." 

History. — He  had  suffered  from  his  stomach  for  ten 
years.  Pain  came  on  about  three  hours  after  food,  and 
might  last  until  he  took  his  next  meal.  The  pain  was  very 
severe,  but  was  promptly  relieved  by  taking  food,  even  a 
drink  of  water  relieved  it.  He  would  be  quite  free  of  pain 
for  weeks  or  months,  and  then  without  any  known  reason 
it  returned.  The  season  of  the  year  had  no  apparent  effect. 
In  August  he  had  one  of  the  recurrences,  and  on  the  morning 
of  the  8th  he  vomited  a  considerable  quantity  of  "  brown 


ACUTE   OR   RECENT   GASTRIC  ULCER        123 

stuff."  He  went  to  work,  but  had  to  return  home  owing  to 
severe  pain.  On  reaching  home  he  vomited  "  half  a  gallon 
of  red  blood."  He  was  kept  in  bed  for  a  fortnight,  and  at 
the  end  of  that  time  he  again  vomited  "  brown  stuff  mixed 
with  red."  He  remained  in  bed  for  three  weeks.  In  the 
second  half  of  September  he  had  another  attack  of  vomiting, 
the  vomit  being  brown  in  colour.  He  remained  in  bed  until 
he  was  sent  to  the  Royal  Infirmary.  He  had  noticed  that 
he  was  always  constipated  during  his  recurring  attacks. 
At  3  a.m.  on  the  morning  after  admission,  having  had  pain 
and  nausea  up  to  that  hour,  he  vomited  sixteen  ounces  of 
material  like  hare  soup.  This  contained  blood  and  much 
free  HCl. 

Examination. — ^There  was  nothing  abnormal  to  note  on 
inspection  of  the  abdomen,  and  there  was  no  tenderness. 
The  stomach  was  enlarged  and  splashed  to  the  right  costal 
margin.  He  was  transferred  to  Professor  Caird  on  the 
17th,  and  operated  on  at  once.  A  large  ulcer  was  present 
near  the  pylorus  on  the  lesser  curve  of  the  stomach.  A 
gastro-enterostomy  was  done. 

Remarks. — It  must  I  think,  be  accepted  that  in  this 
patient  there  had  been  a  long  pre-ulcer  stage  of  hyper- 
chlorhydria  with  stomach  sagging.  The  symptoms  of  ulcer 
appeared  suddenly  in  the  course  of  the  last  of  his  attacks, 
and  they  never  disappeared.  Recurring  haemorrhage, 
vomiting,  and  a  dilated  stomach  left  no  doubt  in  one's  mind 
that  this  was  a  case  for  prompt  surgical  treatment. 


Chronic  Gastric  Ulcer 

Symptoms. — ^The  term  "  chronic  gastric  ulcer  "  is  used  to 
indicate  in  the  first  place  that  symptoms  are  present  which 
warrant  the  diagnosis  of  ulcer,  and  in  the  second  place  that 
the  symptoms  can  be  traced  back  for  weeks,  or  months,  or 
years.  Pain  is  again  the  outstanding  symptom ;  pain 
caused  by  taking  food,  or  coming  on  soon  after  it  is  taken, 
and  being  worse  the  larger  the  quantity  of  food  taken. 

A  history  such  as  this  is  so  definite  that  evidence  has  to  be 


124  THE   STOMACH 

found  that  will  disprove  the  a  priori  presumption.  The  pain 
is  different  from  the  pain  in  hyperchlorhydria  ;  it  comes  on 
sooner,  and  while  it  may  be  alleviated  by  such  drugs  as  give 
marked  relief  in  hyperchlorhydria,  it  is  not  cured.  A  big 
meal  may  lengthen  the  time  before  pain  appears  in  hyper- 
chlorhydria, it  never  does  so  when  chronic  ulcer  is  present. 
Vomiting  is  not  usual,  although  it  may  occur.  Hcemorrhage 
is  common,  but  is  not  invariably  present.  If  present  in 
considerable  amount  it  is  vomited  as  pure  blood.  If  the 
ulcer  is  near  the  pylorus,  so  that  there  is  undue  retention  of 
gastric  contents,  and  slight  bleeding  occurs,  vomiting  is 
common,  and  the  vomit  contains  altered  blood.  There  may 
be  melsena.  The  bleeding  may  be  so  persistent  as  to  cause 
death.  A  certain  proportion  of  cases  perforate  with  escape 
of  gastric  contents  into  the  peritoneal  cavity ;  but  many 
chronic  ulcers  have  formed  adhesions  to  surrounding  parts 
which  prevent  leakage  into  the  peritoneal  cavity.  The 
floor  of  a  chronic  ulcer  on  the  posterior  wall  is  often  the 
pancreas. 

When  the  ulcer  is  at  or  near  the  pylorus  marked  dilatation 
with  undue  retention  of  gastric  contents  is  present,  and  can 
be  demontsrated  by  the  methods  already  described. 

Treatment. — If  a  diagnosis  of  chronic  gastric  ulcer  has 
been  reached  the  fact  has  to  be  definitely  faced  that  medical 
treatment  will  not  heal  it.  The  diagnosis  is  not  difficult  if 
the  patient  is  intelligent.  The  margin  of  error  is  small. 
The  diagnosis  ought  not  to  wait  for  haemorrhage  to  occur, 
for  the  haemorrhage  may  be  fatal,  from  the  involvement 
in  the  chronic  ulcerative  process  of  a  considerable  artery. 
As  regards  surgical  measures  the  mere  performance  of  a 
gastro-enterostomy  is  unsatisfactory.  The  only  satisfactory 
treatment  is  to  deal  directly  with  the  ulcer,  and  if  the  ulcer 
is  near  the  pylorus  this  implies  a  gastro-enterostomy  as  well. 
When  it  is  situated  elsewhere  this  further  procedure  will  not 
be  necessary.  In  bad  cases  of  long  duration,  where  the  floor 
of  the  ulcer  is  formed  by  an  adjoining  organ,  and  there  are 
extensive  adhesions  the  difficulties  the  surgeon  has  to  face 
are  great  and  may  be  insurmountable.     It  is  important  to 


CHRONIC   GASTRIC   ULCER 


125 


recognize  this  fact  and  to  realize  that  it  has  become  the  duty 
of  practitioners  and  physicians  to  diagnose  the  presence  of 
gastric  ulcer  long  before  such  changes  have  had  time  to  be 
produced.  With  surgical  measures  so  eminently  satis- 
factory when  in  the  hands  of  expert  operators,  it  is  to  be 
hoped  that  the  deplorable  cases  of  long-standing  ulcer  will 
soon  be  no  longer  seen  save  as  ancient  relics  in  pathological 
collections. 


Hour-glass    Constriction  :    Chronic   Ulcer  :    Gastro- 
plasty :   Remarkable  Relief 

Case   20.  —  Miss   M.   had   suffered  for  years   from  her 
stomach.     Pain  was  the  prominent  symptom.     The  taking 


X 


Fig 


•Case  20. 


C,  the  position 


Stomach  in  upright  position, 
of  the  contraction. 
This  and  the  two  following  figures  were  kindly  drawn  by  Dr.  Hope 
Fowler,  from  X-ray  plates. 

of  food  caused  so  much  pain  that  it  had  been  reduced  to  the 
smallest  possible  amount  and  the  blandest  procurable.     The 


126 


THE   STOMACH 


result  was  that  she  was  very  lean,  if  not  emaciated,  weak,  and 
unfit  for  physical  effort  of  any  kind.  A  previous  X-ray 
examination  was  understood  to  show  an  hour-glass  con- 
striction of  the  viscus.  Although  the  general  condition  was 
such  as  this,  there  was  no  suggestion  of  cachexia,  and  the 
symptoms  had  lasted  so  long  that  malignancy  was  regarded 
as  improbable.  We  only  succeeded  in  obtaining  a  small 
specimen  of  gastric  contents,  but  it  showed  free  HCl,  which 
strengthened  the  opinion  that  the  condition  was  not  malig- 


FiG.  13. — Same  case  recumbent,  showing  at  C  contracture,  at  U  bismuth 
*in  floor  of  ulcer. 

nant.  The  X-ray  picture  of  the  stomach  is  seen  in  Fig.  12. 
The  hour-glass  constriction  is  well  shown.  The  bismuth 
passed  from  the  proximal  to  the  distal  segment,  and  after  it 
had  left  the  former  it  will  be  seen  in  Fig.  13  that  some 
bismuth  had  remained  behind  at  U.  This  further  confirmed 
the  opinion  that  there  was  a  chronic  gastric  ulcer,  the  bismuth 
being  retained  in  it.  Mr.  Dowden  saw  the  patient,  and 
operation  was  agreed  to.  The  hope  was  that  the  ulcer 
could  be  excised.  On  examining  the  parts  the  channel 
between  the  two  sections  of  the  stomach  was  found  to  be 


CHRONIC   GASTRIC   ULCER 


127 


much  narrower  than  had  been  anticipated.  The  ulcer  was 
large,  and  its  base  was  formed  of  adjoining  structures,  so 
that  its  removal  was  not  attempted.  Mr.  Dowden,  however, 
decided  to  enlarge  the  channel  between  the  two  sections  of 
the  stomach,  and  this  he  effected  by  a  gastroplasty.  The 
patient  made  a  speedy  and  uninterrupted  recovery. 

Remarks. — ^This  case  gave  great  satisfaction  to  all 
interested,  and  to  some  of  us  it  was  illuminating.  The 
patient  not  only  recovered  from  the  operation,  but  the 
operation  relieved  her  of  all  pain.     She  rapidly  increased 


Fig.  13A. — Same  taken  later;  bismuth  out  of  fundus,  present  in  ulcer. 

and  extended  her  diet,  for  she  found  that  food  no  longer 
gave  her  pain.  She  put  on  weight,  regained  strength,  and 
was  able  to  resume  some  of  her  former  activities. 

These  were  the  facts,  yet  the  ulcer  was  there,  and  would 
remain,  for  its  healing  seemed  beyond  possibility.  The 
entire  freedom  from  pain  was  very  striking.  The  explana- 
tion seems  to  be  as  follows.  From  Fig.  12  it  is  seen  that  the 
proximal  section  of  the  stomach  is  quite  definitely  above  the 
distal  section,  so  that  when  the  patient  is  in  the  sitting 
posture  the  food  taken  rapidly  passes  into  the  latter,  where 
it  is  digested  and  in  due  time  passed  on  into  the  duodenum. 


128  TH?:  STOMACH 

The  mere  passage  of  food  over  the  floor  of  the  ulcer  did  not 
cause  pain,  and  there  would  appear  to  have  been  little 
tendency  for  the  contents  of  the  distal  section  to  pass  back 
into  the  proximal  section. 

Chronic   Gastric  Ulcer  :    Tender  C^cum  :    Appendix 
Removed  :    Ulcer  Excised  :    Recovery 

Case  21. — Isabella  M.,  aged  23,  was  admitted  to  the  Royal 
Infirmary  on  the  24th  September,  1915.  The  complaint 
was  of  pain  after  taking  food,  vomiting,  flatulence,  heart-burn, 
palpitation,  and  breathlessness  on  exertion. 

History. — For  four  years  she  had  suffered  from  attacks  of 
pain  and  vomiting  after  food.  She  had  suffered  also  from 
bloodlessness.  For  two  months  she  had  suffered  from  a 
gnawing  pain  after  taking  food.  The  pain  went  through 
to  the  back.  Vomiting  came  on  half  an  hour  after  taking 
food,  and  vomiting  gave  relief.  Twice  or  thrice  before 
going  to  her  doctor  she  vomited  a  little  dark  brown  material. 
She  suffered  for  a  month  before  seeking  medical  advice,  and 
she  was  recommended  to  the  Infirmary  a  month  later. 

Examination. — The  patient  was  thin  and  ansemic  :  the 
height  was  4  ft.  6^  in.,  the  weight  5  st.  12  lb.  The  tongue 
was  moist  and  clean.  Inspection  of  the  abdomen  revealed 
nothing  abnormal.  On  palpation  there  was  tenderness  in 
the  middle  of  the  epigastrium  :  there  was  also  tenderness 
on  deep  pressure  in  the  right  iliac  region.  Pressure  in  this 
region  relieved  the  pain  in  the  epigastrium. 

Treatment. — The  treatment  adopted  was  colon  lavage, 
and  thereafter  regulation  of  the  bowels  by  means  of  a  simple 
laxative.  Belladonna  and  bicarbonate  of  soda  were  given 
to  relieve  the  gastric  pain.  The  treatment  was  persevered 
with  for  nearly  a  month  without  any  real  improvement. 
The  diagnosis  of  a  gastric  ulcer  that  would  not  heal  was 
arrived  at,  and  my  surgical  colleague,  Mr.  Dowden,  saw  the 
patient  with  a  view  to  operation.  At  the  operation  the 
appendix  was  found  to  have  a  narrowed  base  and  a  narrowed 
tip,  but  was  otherwise  healthy  and  there  were  no  adhesions  ; 


CHRONIC   GASTRIC    ULCER  129 

it  was  removed.  The  stomach  showed  an  indurated  ulcer  of 
large  size  on  the  lesser  curve  near  the  cardiac  end.  The 
ulcer  was  excised,  the  edges  of  the  gap  being  brought  together 
transversely  so  as  to  make  the  lumen  of  the  stomach  as  large 
as  possible.  The  operation  was  long  and  difficult,  and  the 
patient  suffered  from  shock,  from  which,  however,  she  soon 
rallied  and  made  an  excellent  recovery.  By  the  12th  of 
November  she  was  able  to  be  out  of  bed. 


Gastric    Ulcer  :    Recurring    Attacks    of    Pain    imme- 
diately   AFTER    Food  :     Vomiting  :     H^matemesis 

AND  MeL.ENA  LATER  :    OPERATION 

Case  22. — George  R.,  aged  54,  bricklayer,  was  admitted 
to  the  Royal  Infirmary  on  the  13th  November,  1915.  The 
complaint  was  pain  in  the  stomach,  sickness  and  vomiting. 
The  history  was  that  three  years  previously  he  began  to  have 
discomfort  and  pain  immediately  after  taking  food,  followed 
by  sickness  and  vomiting  some  hours  later.  The  vomited 
matter  was  very  sour.  Vomiting  gave  relief,  and  slowly 
lessened  the  pain.  He  continued  to  have  attacks  of  this 
kind  for  eighteen  months  ;  the  attacks  coming  on  at  irregular 
intervals  and  lasting  a  week  or  a  fortnight,  followed  by 
intervals  of  freedom  lasting  a  few  weeks  or  longer.  For 
eighteen  months  the  attacks  had  been  more  frequent  and 
more  severe.  The  attack  from  which  he  was  suffering  on 
admission  began  a  fortnight  before.  Pain  of  a  burning 
character  came  on  immediately  after  taking  food,  it  increased 
in  severity,  was  accompanied  by  a  feeling  of  sickness  and  was 
followed  by  vomiting  two  to  four  hours  after  food  had  been 
taken.  The  vomiting  gave  relief.  He  seldom  had  pain 
during  the  night.  He  had  severe  pain  the  evening  before 
admission,  which  continued  until  the  morning  of  admission, 
when  he  was  relieved  by  vomiting.  He  had  considerable 
eructation  of  gas,  especially  after  taking  food.  The  vomited 
matter  he  described  as  greyish-green  in  colour. 

Examination. — There  was  nothing  special  to  be  noted  on 
inspection  of  the  abdomen.     Pain  was  referred  to  the  centre 

9 


130  THE  STOMACH 

of  the  epigastrium,  and  there  was  tenderness  on  palpation  in 
this  region.  The  respiratory  movement  of  the  epigastrium 
was  quite  free.  The  stomach  was  enlarged  and  splashing. 
The  stomach  contents  were  intensely  acid  and  contained 
much  free  HCl.  A  week  after  admission  he  had  hsemate- 
mesis  and  melaena.  He  was  transferred  on  the  22nd 
November  to  my  surgical  colleague,  Mr,  Dowden.  On  the 
25th  he  again  had  hsematemesis  and  melgena  and  was 
operated  on  on  the  26th.  An  ulcer  was  found  near  the 
pyloric  end  of  the  stomach. 

Chronic    Gastric    Ulcer  :    Recurring    Hemorrhage  : 
Death.    Remarks  on  Hemorrhage 

Case  33. — Wm.  C,  aged  39,  was  admitted  on  thei6th  June, 
1918,  in  a  very  enfeebled  and  anaemic  condition,  after  having 
passed  much  blood  from  the  bowel.  The  history  was  that 
he  had  suffered  from  indigestion  for  several  years,  and  had 
been  treated  by  his  doctor.  Patient  had  discomfort  and 
pain  shortly  after  taking  food,  and  he  knew  that  taking 
bicarbonate  of  soda  or  anything  else  did  not  relieve  it. 
He  had  never  vomited  blood,  and  only  once  had  vomited 
food.  He  had  a  haemorrhage  on  the  day  of  admission,  and 
another  on  the  19th,  which  made  his  condition  so  unfavour- 
able that  operation  was  postponed.  Another  on  the  22nd 
was  followed  by  death.  The  post-mortem  examination 
showed  a  large  gastric  ulcer  situated  about  the  middle  of 
the  lesser  curve  and  not  adherent  to  adjacent  structures. 

Remarks. — This  case  is  given  to  illustrate  the  problem 
which  gastric  and  duodenal  haemorrhage  presents  and  tends 
properly  enough  to  bias  judgment.  In  this  patient  we  had 
a  young  man  who  had  symptoms  of  gastric  ulcer  for  some 
time.  There  was  haemorrhage  with  melaena,  but  without 
vomiting,  showing  that  the  blood  must  have  been  poured 
out  slowly  in  the  stomach  and  passed  on  into  the  duodenum. 
The  ordinary  experience  is  that,  under  proper  treatment, 
the  bleeding  in  these  cases  stops  ;  in  this  patient  it  recurred, 
and  finally  led  to  death.     This  has  not  been  common  in 


CHRONIC  GASTRIC  ULCER  131 

my  experience.  Bleeding  commonly  is  arrested,  and  its 
occurrence,  and  even  recurrence,  becomes  part  of  a  history 
which  determines  diagnosis  and  the  question  of  surgical 
treatment.  And  yet  a  case  of  this  kind  comes  into  our 
hands  from  time  to  time,  and  we  regret  that  immediate 
surgical  treatment  was  not  pressed.  The  position  seems 
to  me  to  come  to  this  :  if  there  is  hsemorrhage  from  a  gastric 
or  duodenal  ulcer,  which  from  the  history  has  almost  cer- 
tainly been  present  for  some  time,  the  wiser  course  is  to 
advise  operation  at  once,  not  merely  with  the  intention  of 
doing  a  gastro-enterostomy,  but  of  securing,  if  possible,  that 
the  ulcer  will  not  again  lead  to  hsemorrhage.  The  real 
point  being  that  a  bleeding  ulcer,  unless  definitely  of  quite 
recent  formation,  ought  to  be  operated  on  without  unneces- 
sary delay.  Of  course,  this  brings  one  back  to  the  position 
I  have  already  expounded  that  the  profession  has  to  learn  to 
diagnose  gastric  ulcer  correctly  and  to  realize  the  desirability 
of  not  allowing  cases  of  this  kind  to  drag  on  for  years. 

Pyloric  Obstruction  :  Dilated  Stomach  :  Gastro- 
enterostomy :  Recovery.  No  History  of  Pain  or 
OF  Haemorrhage 

Case  24. — Thomas  W.  T.,  aged  44,  was  admitted  on  the 
nth  July,  1917,  complaining  of  vomiting  and  coldness  of 
legs  and  feet.  The  history  given  was  that  he  had  been  in 
hospital  in  the  North  of  England  six  years  before  and  was 
treated  for  stomach  disorder.  He  did  not  improve,  and  sought 
advice  elsewhere,  and  was  then  treated  for  "  gall-stones." 
He  improved  sufficiently  to  be  able  to  resume  work.  Eight 
months  before  admission  patient  began  to  suffer  from 
constipation — the  bowels  moving  only  every  fourth  day. 
He  also  began  to  vomit,  and  vomited  nearly  every  day ;  the 
vomit  was  pale  in  colour  and  sour.  The  vomiting  usually 
took  place  at  night,  between  seven  and  eight  o'clock. 
When  these  symptoms  had  lasted  a  month,  he  consulted 
his  doctor,  but  received  no  benefit.  He  went  into  hospital 
again,  but  after  a  seven  weeks'  stay  felt  no  better.  There 
was  an  entire  absence  of  complaint  of  pain  in  this  patient. 


132  THE   STOMACH 

Examination. — There  was  considerable  stomach  dilata- 
tion. The  stomach  contents  contained  much  free  acid. 
X-ray  examination  showed  that  six  and  a  half  hours  after 
a  bismuth  meal  none  of  it  had  left  the  stomach. 

Diagnosis. — The  diagnosis  of  non-malignant  pyloric 
obstruction  was  clear.  My  surgical  colleague,  Mr.  i\Iiles, 
operated  on  him  on  the  27th  July,  doing  a  gastro-enterostomy. 
There  was  a  cicatricial  thickening  at  the  pylorus.  The 
patient  made  a  good  recovery. 

Remarks. — The  entire  absence  of  a  record  of  pain  in  this 
case  must  not  be  taken  as  absolutely  correct.  The  patient 
was  in  my  ward  when  we  were  suffering  from  lack  of  efficient 
assistance,  and  one  had  to  be  content  sometimes  with  im- 
perfect records  not  only  of  symptoms  but  even  of  the  details 
of  examination  carried  out  by  oneself.  That  the  patient 
had  suffered  from  pyloric  ulcer  six  years  before  he  was 
admitted  to  the  Edinburgh  Royal  Infirmary  is  almost 
certain  ;  that  the  ulcer  was  chronic  was  shown  by  the 
cicatricial  induration.  And  yet  there  is  the  absence  of  a 
history  of  pain  in  the  record  we  have  ;  which  is  so  unusual 
that  one  is  sceptical  of  its  accuracy,  although  further  ex- 
perience showed  that  the  case  was  not  unique  in  this  respect. 


CHAPTER   XII 

MALIGNANT   DISEASE   OF  THE   STOMACH 

^Malignant  disease  of  the  stomach  as  a  primary  lesion  is 
fairly  common.  It  is  usually  of  carcinomatous  or  adeno- 
carcinomatous  type.  It  may  begin  in  any  part  of  the 
stomach,  but  it  is  probably  more  common  at  or  near  the 
pylorus  than  elsewhere. 

The  phenomena  revealed  by  examination  of  the  abdomen, 
and,  indeed,  the  symptoms  present,  largely  depend  upon 
whether  the  pylorus  is  or  is  not  involved  in  the  neoplasm. 
It  wiU  simplify  the  subject  with  which  this  chapter  deals 
to  begin  with  cases  where  the  pylorus  was  involved.  The 
points  which  lead  to  diagnosis  are  most  effectively  illustrated 
when  considering  individual  cases.  General  principles 
gleaned  from  case-experience  will  be  summarized  later. 

Malignant  Disease  at  Pyloric  End  of  Stomach 

Case  25. — Mrs.  K.,  aged  43,  was  admitted  to  the  Edin- 
burgh Royal  Infirmary  on  the  20th  August,  1906,  complaining 
of  uneasiness  in  the  stomach  and  vomiting,  the  symptoms 
having  lasted  since  June.  The  history  of  the  present  illness 
dated  from  early  in  that  month,  when  she  began  to  suffer 
from  sensations  of  uneasiness  shortly  after  taking  food,  the 
food  often  regurgitating,  but  there  was  no  vomiting.  The 
sensations  came  on,  as  a  rule,  from  half  an  hour  to  an 
hour  after  each  meal.  She  had  also  been  constipated. 
No  history  of  any  kind  of  gastric  or  digestive  disorder  before 
June  could  be  obtained  by  the  most  direct  questioning. 
She  had  become  gradually  worse — treatment  giving  her  no 
relief.     The    eructations    increased,    vomiting    began    and 

133 


134  THE   STOMACH 

became  more  frequent.  As  she  was  rapidly  becoming 
weaker  and  losing  flesh,  she  came  to  the  Infirmary.  She 
had  noticed  for  some  time  a  lump  in  the  upper  part  of  the 
abdomen. 

Examination  of  the  alimentary  tract  showed  the  gums 
to  be  edentulous,  the  result  of  complete  extraction  ;  and 
the  tongue  was  flabby,  with  a  slight  fur.  The  appetite  was 
fairly  good.  After  meals  there  was  a  feeling  of  distension  of 
the  abdomen,  and  she  was  conscious  of  movements  and 
rumblings  in  its  upper  part.  She  felt  drowsy  and  heavy 
after  food.  She  vomited  frequently  after  admission,  the 
vomit  consisting  of  the  food  she  had  taken  but  little  altered, 
and  when  she  was  allowed  bread  the  vomit  contained  great 
pieces  of  undigested  bread  crust.  Ultimately  we  minced 
all  her  food,  but  that  only  led  to  a  temporary  diminution  in 
the  frequency  with  which  she  vomited.  The  vomit  never 
contained  free  hydrochloric  acid,  nor  did  the  gastric  con- 
tents withdrawn  by  the  tube  after  a  meal.  There  was  a 
pear-shaped  lump  to  the  right  of  the  epigastrium  ;  movable, 
and  not  seemingly  adherent  to  deeper  structures.  The 
smaller  end  of  the  lump  was  to  the  right.  The  stomach 
was  considerably  dilated,  its  inferior  border  reaching  to  the 
umbilicus  and  the  fundus  to  the  fifth  rib. 

Remarks. — In  this  case  there  was  what  is  commonly 
called  a  tumour  in  the  upper  part  of  the  abdomen.  It  was 
a  somewhat  pear-shaped  swelling,  running  from  above 
downwards  and  to  the  right,  the  smaller  end  being  its  right 
inferior  end.  The  mass  was  usually  hard,  easily  felt,  and 
to  a  small  extent  movable.  The  stomach  was  dilated,  its 
boundaries  being  easy  to  define  by  succussion  and  percussion. 
The  succussion  wave  could  be  felt  right  up  to  this  mass.  A 
point  of  clinical  interest  was  that  the  mass  altered  in  cha- 
racter ;  it  became  so  soft  that  it  required  the  expert  hand 
to  be  sure  of  its  existence.  Further,  waves  of  stomach  contrac- 
tion were  often  to  be  seen  passing  across  the  upper  part  of  the 
abdomen  and  ending  in  the  mass.  The  mass  was  the  thickened 
-wall  of  the  pyloric  end  of  the  stomach — its  position,  shape, 
altering  thickness,  and  its  relation  to  the  greater  and  lesser 


MALIGNANT  DISEASE  135 

curves  of  the  stomach,  all  confirmed  this.  There  had  been 
no  haematemesis,  no  coffee-ground  vomit,  no  melsena.  There 
had  been  an  entire  absence  of  gastric  s^-mptoms  until  June, 
but  once  they  began  there  had  been  no  material  remission  in 
them  ;  discomfort  and  vomiting,  especially  vomiting,  had 
become  pronounced.  The  vomit,  and  the  stomach  contents 
removed  by  the  tube,  never  showed  a  trace  of  free  hydro- 
chloric acid.  That  there  was  pyloric  obstruction  was  shown 
b}'  the  retention  of  food  in  the  stomach.  That  the  stomach 
was  not  larger  than  it  was,  and  that  there  was  no  marked 
fermentation  of  its  contents,  was  due  to  the  ease  and  regu- 
larity with  which  the  stomach  had  hitherto  emptied  itself  by 
vomiting  when  discomfort  became  considerable.  The  dia- 
gnostic points  in  the  case  were  the  "  tumour,"  which  varied 
in  thickness  and  hardness,  and  might  be  said  at  times  to 
disappear ;  visible  gastric  peristalsis ;  vomiting.  These 
three  points  indicated  pyloric  obstruction,  with  marked 
spasmodic  contraction  of  the  pylorus. 

The  two  conditions  which  give  rise  to  pyloric  spasm,  as 
marked  as  it  was  in  this  case,  and  to  visible  peristalsis,  are 
simple  ulcer  and  malignant  growth  at  the  pylorus.  There 
was  no  history  of  simple  ulcer,  nor  were  the  symptoms 
those  of  simple  ulcer  near  the  pylorus,  and  therefore  we  con- 
cluded that  there  was  a  mahgnant  growth  there.  The  onset, 
the  course,  the  condition  on  admission,  the  absence  of  free 
hydrochloric  acid,  all  supported  this.  A  great  part  of  the 
difficulty  commonly  experienced  in  making  differential 
diagnosis  in  gastric  and  abdominal  disease  is  really  due  to 
a  want  of  definite  knowledge  as  to  the  lesions  which  occur 
in  different  viscera,  and  as  to  the  symptoms  which  are 
practically  inseparable  from  each. 

In  this  case  there  was  no  doubt  that  the  "  tumour  "  was  the 
pyloric  end  of  the  stomach.  I  once,  after  a  hurried  examina- 
tion, thought  a  "  tumour  "  of  this  nature  a  displaced  kidney, 
but  I  speedily  rectified  my  error.  If  we  consider  next  its 
nature,  we  conclude  that  much  of  it  was  due  to  muscular 
contraction  of  the  pyloric  wall,  for  it  went  and  came  to  a 
considerable  extent.     This  is  not  uncommon.     As  to  the 


136  THE   STOMACH 

explanation  of  the  muscular  spasm,  it  is,  in  my  experience, 
due  to  irritation,  caused  either  by  a  chronic  open  ulcer  near 
the  pylorus,  or  to  an  infiltrating  cancer  in  the  same  region. 
We  excluded  simple  ulcer,  and  when  that  was  done  there 
was  no  escape  from  the  alternative.  If  an  ulcer  is  malignant, 
there  is  only  one  method  of  treatment  of  any  avail,  and  that 
is  removal.  In  advanced  cases,  where  pylorectomy  is  not 
practicable,  gastro-enterostomy  is  often  advisable  for  the 
relief  of  symptoms.  Which  procedure  is  to  be  possible,  can 
sometimes  only  be  determined  after  the  surgeon  has  opened 
the  abdomen.  In  the  above  case,  owing  to  the  mobility  of 
the  "  tumour,"  we  hoped  it  might  be  found  removable. 

This  patient  was  operated  on  by  Mr.  Caird  on  the  29th 
September,  when  a  pylorectomy  was  done,  followed  by  a 
gastro-enterostomy.  The  pyloric  end  of  the  stomach  showed 
much  thickening  and  contraction  of  the  pyloric  muscle, 
while  near  the  pyloric  opening  there  was  one  of  those  large 
circular  growths,  with  a  raised  fungus-like  margin  and  an 
atrophied-looking  centre,  which  experience  has  shown  to  be 
malignant.  There  was  no  affection  either  of  the  lymph 
glands  or  of  the  liver,  so  far  as  could  be  seen.  Sections  of 
the  removed  pylorus  made  by  Mr.  Wade,  F.R.C.S.E.,  one 
of  the  assistant  pathologists,  showed  the  condition  to  be  an 
infiltrating  cancer. 

The  patient  made  an  uninterrupted  and  rapid  recovery, 
and  was  able  to  return  to  her  home  in  the  course  of  from 
three  to  four  weeks.  She  died  two  to  three  years  later  of 
recurrence. 

Case  26. — Mrs.  C,  aged  63,  admitted  on  the  15th  January, 
1 916,  was  sent  to  me  by  Dr.  Melville,  Penicuik.  She  had 
been  under  treatment  for  stomach  symptoms  for  some  months 
without  material  improvement  in  her  condition. 

History. — During  the  summer  before  admission  she  had 
suffered  very  greatly  from  flatulence,  a  nev/  experience  to 
her,  for  she  had  never  been  ill.  In  August,  after  a  day  in 
Edinburgh,  she  was  very  "  done-up."  From  the  beginning 
of  September  she  rested  and  lived  on  milk,  but  without 
improvement.     It  required  very  direct  questioning  to  bring 


MALIGNANT  DISEASE  137 

out  the  significance  of  those  early  months.  She  denied  having 
suffered  any  pain  or  that  fluid  material  was  ever  eructated. 
When  asked  about  her  appetite,  she  granted  that  it  was  not 
good  at  that  time,  that  she  had  no  desire  for  food,  and  that 
therein  lay  a  difference  from  her  ordinary  condition.  When 
asked  if  she  felt  she  was  weaker  at  that  time,  she  granted 
that  she  was  "not  going  out  so  much,"  as  she  felt  tired 
after  it.  She  then  volunteered  the  information  that  she  did 
not  always  get  up  to  breakfast.  In  fact,  there  was  a  clear 
history  to  be  wormed  out  of  our  patient  of  a  definite  and 
progressive  debility,  which  in  her  mind  was  so  associated 
with  flatulence,  that  flatulence  became  the  malady,  and 
progressive  debility  merely  a  side  manifestation  of  it,  and 
inevitable.  This  was  the  part  of  the  picture,  or  of  the  history, 
which  required  some  skill  to  fill  in,  and  the  importance  of  it 
was  great,  for  it  gave  a  picture  of  the  early  weeks  and  months 
of  a  stomach  cancer  in  a  patient  of  63  years  of  age.  This 
phase  continued  until  November,  when  vomiting  was  added 
to  the  symptom  of  flatulence.  For  a  fortnight  she  vomited 
every  second  day,  then  the  vomiting  fell  to  every  third  or 
fourth  day,  and  at  one  time  there  was  no  vomiting  for  three 
weeks.  Then  there  were  daily  attacks  for  a  fortnight, 
followed  by  ten  days  of  freedom.  On  the  nth  January 
vomiting  more  severe  than  ever  came  on,  and  she  was 
admitted  to  the  Royal  Infirmary  on  the  15th.  The  descrip- 
tion of  the  vomited  matter  was  that  it  varied  in  quantity 
from  two  to  four  breakfastcupfuls.  It  was  either  greyish 
or  brown  in  colour,  of  a  bitter  taste,  and  sometimes  as  thick 
as  gruel.  There  was  no  feeling  of  nausea  and  no  pain  before 
vomiting.  The  vomiting  removed  a  feeling  of  distension  of 
the  stomach  which  preceded  it.  The  bowels  moved  fairly 
regularly,  but  the  dejecta  varied  in  colour  and  in  consistence. 

Family  History.— The  patient's  mother  died  of  "  blockage 
of  gullet  "  ;  a  sister  died  of  cancer  at  the  age  of  50. 

Condition  on  Admission.^The  patient  was  still  plump, 
although  she  had  lost  much  in  weight.  The  expression 
was  that  of  a  calm,  self-possessed,  steadfast  character.  The 
face  colouring  suggested  cachexia  rather  than  pure  anaemia. 


138  THE  STOMACH 

Abdomen. — The  abdomen  was  large,  and  showed  consider- 
able fat  in  its  wall.  There  was  a  fulness  in  the  right  iliac 
region,  not  present  in  the  corresponding  area  on  the  left 
side.  On  palpation  in  this  region,  there  was  a  definite  elastic 
swelling,  which  felt  so  like  a  cyst  that  it  suggested  either  a 
right  ovarian  cyst  or  a  displaced  and  cystic  kidney  ;  it  was 
not  tender.  On  examination  of  the  epigastrium,  there  was 
palpable  what  at  first  was  thought  to  be  the  liver,  but  on 
more  careful  palpation  was  clearly  not  liver.  It  was  a 
pear-shaped  swelling,  the  thick  end  of  which  was  to  the  left ; 
it  lay  transversely  in  the  epigastrium  from  the  edge  of  the 
ribs  on  the  left  side.  It  was  not  painful  on  pressure.  On 
percussion  the  area  of  normal  fundus  tympanicity  was  not 
only  present,  but  was  considerably  extended  upwards  and 
to  the  left.  During  the  few  days  the  patient  was  in  hospital 
there  was  frequent  vomiting,  consisting  of  thickish,  grey- 
coloured  material  consisting  of  little  pieces  of  curd  of  milk, 
of  gruel,  or  of  the  starch  of  bread  she  ate.  At  other  times 
it  was  more  fluid  and  brown  in  colour.  The  vomiting  was 
not  preceded  by  pain  or  nausea,  and  the  vomit  was  brought 
up  without  discomfort.  No  specimen  of  the  vomited  matter 
contained  free  HCl.  The  bowels  were  easily  acted  upon  by 
means  of  water  allowed  to  pass  slowly  into  the  bowel  from  a 
douche-can.  There  were  no  enlarged  glands  above  the  clavicle. 

Diagnosis. — The  diagnosis  was  malignant  disease  of  the 
pyloric  third  of  the  stomach,  and  that  the  condition  was 
inseparable.  The  cystic-like  swelling  in  the  right  iliac  region 
did  not,  in  view  of  this  diagnosis  and  in  the  absence  of 
symptoms  which  could  be  attributed  to  it,  require  further 
measures  of  examination,  such  as  cystoscopy  or  the  collection 
of  urine  from  the  individual  kidneys.  Both  Dr.  Haig  Fergu- 
son and  Mr.  Dowden  kindly  saw  this  patient  with  me. 

Remarks. — The  early  history  of  this  case  as  it  has  been 
presented  is  not  unique :  it  is  a  picture  of  what  usually 
happens  in  malignant  disease  of  the  body  of  the  stomach. 
Pain  is  often  absent  if  considerable  ulceration,  or  irritation 
leading  to  adhesions  to  contiguous  parts,  has  not  occurred. 
The  failure  of   appetite ;    the  loss  of   desire  for  food ;  the 


MALIGNANT  DISEASE  139 

slowly  progressing  debility  without  any  blood  lesion  beyond 
secondary  an?emia ;  the  loss  of  weight ;  the  prominence  of 
a  gastric  symptom,  such  as  flatulence  was  in  this  case ;  and 
the  failure  of  medical  measures  to  improve  the  appetite,  to 
stop  the  flatulence,  to  arrest  the  progressive  weakness,  all 
suggest  to  the  experienced  physician  that   malignancy  is 
in  the  background,  although  there  is  nothing  abnormal  to 
be  made  out  on  palpation  of  the  abdomen.     A  test  meal 
and  the  examination  for  free  HCl  is  valuable  at  this  stage, 
for,    if   free   HCl  be  absent,   it  so   strongly  supports  the 
diagnosis  of  malignancy  that  the  question  of  opening  the 
abdomen  becomes  urgent,   in  the  hope  that  the  condition 
is  early  and  sufficiently  localized  to  allow  of  its  removal  by 
the  surgeon.     In  a  case  like  this  there  are  thus  two  practical 
questions  set  to  the  clinician  :  (i)  Is  it  malignant  ?     (2)  Is 
the  surgeon  likely  to  be  able  to  remove  it  ?     The  second 
question  hangs  upon  the  first,  and  this  is  why  it  is  so  important 
to  make  an  early  diagnosis.     The  picture  I  have  given  of 
the  first  few  months  of  indisposition  in  a  hitherto  healthy 
woman  ;    with  no  discoverable  lesion  in  any  other  organ  ; 
and  who   does  not  respond  to  intelligent  treatment,  may 
lead,  ought  indeed  to  lead,  to  this  point,  namely,  that  the 
patient  is  so  probably  suffering  from  malignant  disease  that 
one   has  to  prove  the  negative  ;    and   if   that   cannot    be 
done,  one  must  remember  that  a  cancer  of  the  body  of  the 
stomach  can  only  be  removed  if  taken  early.     This  early 
period  in  our  patient  lasted  for  fully  three  months.     It  was 
not  until  November  that  vomiting  became  a  symptom  ;  once 
it  started  it  continued,  although  at  varying  intervals — every 
day  or  two,  or  even  with  a  break  of  three  weeks.     The 
vomiting  latterly  became  more  frequent  and  persistent,  while 
during  the  days  she  was  in  the  Infirmary  she  vomited  oftener 
than  once  each  day.     There  was  no  pain  before  the  vomiting, 
nor  nausea,  only  a  certain  sense  of  fulness  was  relieved  by  it. 
It  seemed  as  if  whatever  nourishment  she  took  accumulated 
in  the  somewhat  large  fundus,  and  after  lying  there  for  a 
time  was  simply  ejected,  while  little  of  it  passed  along  the 
pyloric    end    to    the    duodenum.     The    state    of    nutrition 


140  THE   STOMACH 

warranted  the  assurance  that  some  nutriment  passed.  From 
the  history  I  think  it  may  be  assumed  that  the  mahgnancy 
did  not  begin  right  at  the  pylorus  ;  had  it  done  so  there 
would  earlier  have  been  evidences  of  pyloric  obstruction. 
As  soon  as  malignancy  occurs  at  the  pylorus  it  gives  rise  to 
pyloric  spasm,  with  retention  of  gastric  contents,  early 
gastric  dilatation,  and  vomiting  of  retained  contents.  In 
the  present  case  vomiting  was  a  later  symptom,  and  when 
it  did  appear  it  was  so  regularly  and  easily  accomplished  that 
no  great  dilatation  of  the  fundus  had  developed.  By  the 
time  she  was  admitted  to  the  ward,  the  whole  pyloric  antrum, 
judging  by  its  uniformly  thickened  condition,  was  involved. 

As  to  medical  treatment,  it  is  unfortunately  confined  to 
amelioration  of  symptoms,  and  to  giving  as  much  concentrated 
and  predigested  or  readily  digested  food  as  possible.  Our 
first  duty  as  physicians  and  practitioners  is  early  diagnosis, 
and  I  do  not  minimise  the  difficulty  of  early  recognition. 
The  rule  to  guide  us  may  be  laid  down  as  follows  : — When 
patients  who  suffer  from  gastric  disturbance,  and  who  have 
been  treated  along  sound  lines  without  benefit,  and  especially 
if  they  lose  weight  and  complain  of  unwonted  muscular 
debility,  it  is  our  duty  to  no  longer  assume  that  the  case 
is  only  one  of  ordinary  indigestion  or  dyspepsia,  but  to  have 
it  thoroughly  investigated  with  a  view  to  determine  whether 
or  no  it  is  malignant.  The  methods  of  examination  are 
palpation,  percussion,  test  meals,  and  X-ray  examination, 
and  the  exclusion  of  disease  in  other  organs  which  might 
simulate  malignant  disease  of  the  body  of  the  stomach. 
In  some  cases  malignant  disease  may  be  so  situated  in  the 
body  of  the  stomach  that  palpation  and  percussion  give  no 
data  and  where  the  diagnosis  is  determined  by  the  history  and 
the  phenomena  grouped  round  it,  and  the  absence  of  free 
HCl. 

Carcinoma  of  Pyloric  Antrum  without  Pyloric 
Obstruction 

Case  27. — Mrs.  S.,  aged  53,  was  admitted  to  the  Infirmary, 
as  gastric  ulcer  with  hsematemesis,  in  February,  1919. 


MALIGNANT   DISEASE  141 

History. — The  history  was  that  on  the  two  days  before 
admission  she  had  vomited  blood  ;  on  the  first  occasion 
the  vomit  was  red  in  colour,  on  the  second  it  was  chocolate- 
coloured.  She  denied  ever  having  suffered  from  indigestion 
or  stomach  trouble  of  any  kind.  The  appetite  was  good 
and  she  "  could  eat  anything." 

After  Admission.  —  She  was  put  on  our  ordinary 
regimen  for  gastric  ulcer  ;  and  the  colon  was  cleared  out 
by  lavage.  The  motions  resulting  from  lavage  were  black 
in  colour  (melccna)  ;  thereafter  the  colour  became  normal. 
There  was  such  a  definite  absence  of  gastric  discomfort 
that  the  diet  was  rapidly  added  to  until  she  was  taking 
porridge  and  milk  and  fish  and  farinaceous  pudding  in 
addition  to  bread  and  butter. 

Cases  of  this  kind  are  common  and  my  attention  was 
not  drawn  to  this  case  for  some  days.  I  then  found  on 
palpation  a  sausage-shaped  swelling  lying  transversely  in 
the  middle  of  the  epigastrium  above  the  level  of  the 
umbilicus  ;  it  was  not  tender  and  it  moved  with  respira- 
tion. There  was  no  dilatation  of  the  stomach.  After  a 
day  or  two  the  sausage-shaped  mass  lying  in  the  middle 
of  the  epigastrium  was  represented  by  an  irregular  mass 
or  lump  lying  to  the  left  of  the  mesial  plane  at  the  same 
level,  which  measured  about  two  inches  square.  At  this 
stage  it  was  apparent  that  the  mass  must  be  on  the  proximal 
side  of  the  pj^lorus,  for  the  simple  reason  that  with  such 
an  entire  absence  of  dilatation  and  of  food  retention  the 
pyloric  outlet  could  not  be  encroached  upon.  That  the 
mass  was  a  stomach  neoplasm  was  almost  beyond  question. 
An  old  gastric  ulcer  with  thickening  would  certainly  have 
given  a  history  of  long  stomach  suffering.  A  test  meal 
showed  entire  absence  of  free  HCl. 

X-ray  examination  by  Dr.  Hope  Fowler  in  the  Electrical 
Department  was  reported  on  as  follows  :— "  J\Ieal  given  at 
time  of  examination.  Note  that  meal  is  filling  the  greater 
part  of  the  cardiac  and  pyloric  portions  of  stomach,  the 
pyloric  portion  towards  the  distal  end  is  seen  to  be  deformed 
(the  opaque  meal  is  seen  to  pass  round  something  which 


142  THE   STOMACH 

deforms  it).     The  whole  of  the  duodenum  is  faintly  out- 
lined." 

Mr.  Dowden,  one  of  my  surgical  colleagues,  saw  the 
patient  and  agreed  with  the  view  that  there  was  a  neoplasm 
not  involving  the  pjiorus.  The  absence  of  free  HCl  indicated 
in  my  experience  that  the  neoplasm  was  malignant.  Yet 
the  entire  absence  ot  symptom,  of  any  suggestion  of  cachexia, 
the  absence  of  loathing  of  food,  and  the  occurrence  of  early 
haematemesis  and  melsena  were  all  so  imusual  that  the  hope 
was  expressed  that  it  might  be  a  simple  growth  associated 
with  absence  of  free  HCl.  The  possibility  of  recurrence  of 
haemorrhage  was  the  determining  factor  in  favour  of  imme- 
diate operation.  At  the  operation  it  was  decided  that  it  was 
malignant,  so  the  part  was  resected  and  a  gastro-enterostomy 
done.  The  patient  stood  the  operation  well  and  made  a 
satisfactory  recovery. 

Combination  of  Gall-stones  and  Malignant 
Obstruction  of  Pylorus  :  Operation 

Case  28. — Mrs.  B.,  aged  49,  was  sent  to  me  for 
opinion  and  advice  as  to  treatment  in  September,  191 8. 
She  was  well-nourished  with  no  suggestion  in  her  appear- 
ance of  cachexia. 

The  complaint  was  of  vomiting,  which  occurred  daily 
and  had  lasted  for  three  months  or  thereby.  She  had  lost 
weight,  although  still  plump,  and  was  weaker. 

History. — The  history  was  that  four  years  before  she  had  a 
very  severe  attack  of  pain  in  the  region  of  the  liver,  and 
vomiting ;  the  attack  was  diagnosed  as  gall-stone  colic. 
The  attack  passed  off  and  there  was  no  recurrence  until 
three  years  afterwards  when  the  same  character  of  symptoms 
appeared  associated  with  jaundice ;  the  same  diagnosis 
was  made.  She  again  had  an  interval  of  freedom  for  about 
a  year  until  June,  when  she  was  again  seized  with  pain 
and  vomiting  but  without  jaundice.  The  pain  passed  off, 
as  the  pain  on  the  two  previous  occasions  had  passed,  but 
the  vomiting  persisted  and  had  continued  to  the  present 
time. 


MALIGNANT   DISEASE  143 

Examination.  —  There  was  not  a  trace  of  jaundice. 
The  abdomen  was  lax  but  showed  a  considerable  thickness 
of  fat.  On  palpation  there  was  a  mass  palpable,  under  the 
right  costal  margin  and  projecting  from  it,  about  the  size 
of  a  medium-sized  pear  and  elongated  in  shape  ;  it  was  in 
the  vertical  parasternal  line,  close  to  the  abdominal  wall, 
and  moved  with  the  movements  of  the  diaphragm  on  deep 
breathing.  It  felt  like  a  gall-bladder  tightly  contracted  on 
its  contents,  and  it  was  thought  to  be  the  gall-bladder  full 
of  calculi  probably  of  a  large  size.  This  was  also  consistent 
with  the  history  of  gall-stone  colic  extending  back  for 
four  years.  This,  however,  could  not  be  taken  as  the  cause 
of  the  persistent  vomiting.  On  further  examination  it 
was  easily  demonstrated  that  the  stomach  was  much 
dilated  and  that  there  was  large  retention  of  food.  The 
stomach  succussion  wave  reached  to  the  right  of  the  middle 
line  and  ended  very  abruptly  and  definitely.  The  stomach 
contents,  which  were  vomited  soon  after  the  examination, 
showed  no  free  acid,  while  the  food  was  well  broken  up. 

Comment  and  Diagnosis. — From  the  foregoing  observa- 
tions it  was  concluded  that  the  attacks  of  gall-stone  colic 
had  been  caused  by  calculi  in  the  gall-bladder  which  were 
not  escaping  from  it ;  that,  in  addition,  there  was  pyloric 
obstruction  with  almost  complete  retention  of  gastric 
contents.  The  absence  of  free  HCl  was  regarded  as  of  very 
grave  significance  as  indicating  that  the  stenosis  was  almost 
certainly  malignant.  Questions  remained  to  be  answered  ; 
the  first  was  as  to  the  palpable  lump  or  mass.  It  seemed 
to  be  the  gall-bladder  judging  by  its  position,  its  outline, 
and  in  view  of  the  history.  If  it  were  the  gall-bladder,  was 
it  possible  that  it  could  press  upon  the  pylorus  ;  and  had  it 
formed  adhesions  leading  to  a  constriction  of  the  pylorus  ? 
Both  these  ideas  were  set  aside  as  improbable.  The  other 
question  was  :  Is  it  not  the  pylorus  ?  This  possibility  could 
not  be  set  aside,  although  one  had  not  previously  felt  a  pylorus 
like  this  or  in  this  position.  However  that  might  be,  there 
was  no  doubt  about  the  history  of  gall-stone  colic,  and  there 
was  no  doubt  about  the  stomach  dilatation  due  to  almost 


144  THE  STOMACH 

complete  stenosis  of  the  pyloric  outlet.  The  treatment  was 
clearly  surgical.  Before  submitting  the  case  to  a  surgical 
colleague  one  completed  the  case  by  having  the  patient 
screened  and  photographed  after  taking  bismuth.  The 
X-ray  examination  was  made  by  Dr.  Hope  Fowler ;  it  showed 
the  dilated  stomach,  and  the  abrupt  right  border,  but  no 
trace  of  bismuth  to  indicate  the  position  of  the  pylorus. 
This  plate  was  taken  some  thirty  hours  after  the  bismuth 
had  been  taken,  and  it  had  all  been  retained.  There  was, 
Dr.  Fowler  pointed  out,  a  faint  shadow  between  the  stomach 
and  the  liver  edge,  but  the  X-ray  plate  did  not  show  it 
to  be  pylorus  rather  than  a  distended  gall-bladder. 

Professor  Caird  saw  the  patient  and  had  the  history 
and  phenomena  described,  submitted  to  him,  and  he  agreed 
as  to  the  necessity  for  surgical  interposition.  When  under 
the  anaesthetic  the  lump  in  question  was  freely  movable 
and  could  be  pushed  to  the  middle  line,  which  negatived 
the  possibility  of  its  being  gall-bladder.  On  the  abdomen 
being  opened  the  mass  was  seen  to  be  a  greatly  and  uniformly 
thickened  pylorus,  with  abrupt  ends,  measuring  fully  three 
inches  in  length,  very  freely  movable  without  a  single 
adliesion.  The  stomach  was  very  large.  The  gall-bladder 
was  full  of  calculi.  The  case  seemed  an  ideal  one  for 
pylorectomy,  but  the  operation  was  a  long  one  and  proved 
too  much  for  the  patient's  strength,  for  she  died  the 
following  day.  It  would  have  been  safer  to  have  been 
content  with  a  gastro-enterostomy  as  a  first  step,  but 
even  the  physician  could  recognize  the  special  attractive- 
ness of  the  radical  operation  in  view  of  a  free  pylorus  and 
the  absence  of  metastasis. 

The  case  illustrates  the  association  of  diseases  which 
had  no  apparent  relation  to  each  other,  and  the  importance 
of  a  complete  diagnosis.  It  was  of  special  interest,  as  I 
had  never  seen  a  case  in  which  the  question :  Was  it  gall- 
bladder or  pylorus  ?  was  so  difficult  to  answer  satisfactorily. 
Tlie  question  was,  fortunately,  purely  academic  and  in  no 
way  affected  the  decision  that  the  stomach  had  to  be  given 
an  outlet  for  its  contents  other  than  by  the  oesophagus  ; 


MALIGNANT  DISEASE  145 

and  there  was  equally  no  doubt  that  there  were  calculi  in 
the  gall-bladder. 

Carcinoma  Pyloric  Antrum  :  Much  Vomiting  : 
Relieved  by  Gastro-enterostomy 

Case  29. — George  M.,  aged  48,  was  admitted  to  the 
Royal  Infirmary  on  the  24th  April,  1919. 

History. — Six  months  before  admission,  he  began  to  suffer 
from  indigestion  and  constipation.  The  indigestion  showed 
itself  by  pain  and  discomfort  about  an  hour  after  food  was 
taken.  There  was  loss  of  appetite.  There  was  a  sense 
of  general  weakness  and  he  soon  got  tired  at  work.  Constipa- 
tion was  relieved  by  Epsom  salts.  He  continued  to  work 
for  four  months,  when,  after  consulting  his  doctor,  he  began 
to  diet  himself.  Since  then  his  diet  had  been  gradually 
reduced  and  for  three  weeks  he  had  taken  milk  only. 
He  had  become  steadily  weaker  and  had  lost  two  stones  in 
weight  in  two  months.  During  the  last  six  weeks  vomiting 
had  become  more  and  more  frequent,  so  that  he  was 
afraid  to  take  food.  If  he  took  solids  he  vomited  at  once, 
but  he  could  retain  liquids  for  a  variable  time.  If  vomit- 
ing was  delayed  he  recognized  food  he  had  taken  sixteen 
or  eighteen  hours  previously.  Latterly  the  smell  of  food 
had  been  sufficient  to  make  him  vomit.  Thirst  had  been 
very  troublesome.     He  had  constant  nausea. 

Examination. — ^The  patient  was  very  emaciated.  The 
abdomen  was  sunken.  There  was  no  visible  peristalsis.  There 
was  no  tenderness  anywhere.  There  was  an  indefinite 
and  ill-defined  swelling  in  the  epigastrium  through  which 
the  pulsation  of  the  abdominal  aorta  was  conducted.  There 
was  an  area  of  typanicity  stretching  from  the  fourth  to  the 
seventh  left  space  and  lying  between  the  costal  margin 
and  the  mid-axillary  line.  No  splash  was  obtained.  The 
vomit  contained  no  free  acid,  neither  hydrochloric  nor  lactic. 
The  diagnosis  was  clearly  malignant  disease  at  the  pyloric 
end  of  the  stomach.  X-ray  examination  showed  the 
bismuth  meal  confined  to  the  area  of  tympanicity  described 
above,  which  was,  of  course,  the  stomach  fundus  ;  in  the 

10 


146  THE  STOMACH 

recumbent  position  this  portion  tapered  to  the  right  and  a 

trickle  of  bismuth  was  seen  in  it. 

Remarks.^ — As    has    been    stated    there   was   no   doubt 

about   the   diagnosis,  but   the   question   was   whether   the 

patient  was  to  be  left  to  get 
worn  out  by  the  vomiting.  The 
position  was  explained  to  him 
and  he  was  willing  to  be 
operated  on.  My  colleague,  Mr. 
Miles,  kindly  saw  him  and 
operated  on  the  24th  April. 
Neoplasm  was  found  invading 
the  pylorus  and  the  whole  of  the 

FIG.  i4-Case29.^^P,  pylorus;    antrum,  extending  further  on  the 

posterior  than  on  the  anterior  wall. 
A  posterior  gastro-enterostomy  was  performed.  He  made  a 
good  recovery  and  returned  home  freed  from  discomfort  and 
able  to  take  nourishment.  The  annexed  figure  indicates  the 
area  of  involvement  of  the  stomach  wall.  That  surgical 
treatment  is  known  to  be  only  palliative  in  cases  of  this 
kind  does  not  seem  to  me  to  contra-indicate  operation,  and 
I  have  no  hesitation  in  recommending  it.  The  relief  for 
the  time  is  great  and  later  symptoms  are  less  distressing.  1 

The  two  following  cases,  which  were  seen  as  this  book 
was  in  the  press,  are  added  as  they  strikingly  illustrate  the 
importance  of  early  diagnosis,  and  as  they  prove  how  entirely 
fallacious  age  incidence  may  be. 

Case  29a. — Miss  I.,  aged  33,  was  seen  in  consulta- 
tion on  the  17th  April,  1920.  The  symptoms  sug- 
gested gastric  ulcer  near  the  pylorus.  She  went  into  a 
nursing  home,  and  was  treated  by  her  ordinary  medical 
attendant.  The  symptoms  disappeared,  and  her  general 
condition  improved.  After  leaving  the  home,  she  spent 
the  month  of  June  at  the  seaside,  and  was  reported  to  be 
well.  In  July  she  went  to  the  Highlands  and  symptoms  of 
gastric    disturbance    again    appeared.     She    continued    to 

^  The  notes  of  this  case  were  taken  by  my  House  Physician,  Dr.  Ross 
Haddon. 


MALIGNANT   DISEASE  147 

suffer  and  became  decidedly  weaker  and  unfit  for  physical 
effort.  She  consulted  the  local  doctor  in  the  middle  of 
August.  He  saw  that  she  was  weak  and  anaemic,  and  pre- 
scribed iron.  She  felt  some  improvement  under  this  treat- 
ment. She  returned  to  Edinburgh  in  the  beginning  of 
September,  and,  notwithstanding  the  persistence  of  weak- 
ness and  of  inability  to  take  much  nourishment,  she  did  not 
consult  her  medical  attendant.  For  two  or  three  weeks  she 
had  vomited  frequently.  On  the  29th  of  November  she 
came  to  see  me,  when  I  was  shocked  at  her  appearance,  and 
insisted  that  she  must  at  once  get  her  doctor  to  see  her.  I 
saw  her  with  him  two  days  later,  and  could  only  confirm 
his  diagnosis  of  a  malignant  mass  in  the  pyloric  part  of  the 
stomach.  The  mass  was  roughly  nodulated,  very  hard,  and 
not  movable.  The  hope  was  entertained  that  a  gastro-enter- 
ostomy  might  be  feasible,  although  there  seemed  to  be 
no  prospect  that  the  mass  which  was  felt  could  be  removed. 
>\Ir.  Dowden  opened  the  abdomen  and  found  the  stomach 
so  extensively  affected  and  adherent  to  the  liver  that  a 
gastro-enterostomy  could  not  be  done. 

Remarks. — This  is  a  very  tragic  story  and  not  a  very 
uncommon  one.  It  teaches  various  lessons.  In  the  month 
of  April  the  symptoms  did  not  arouse  any  suspicion  of  the 
possibility  of  malignancy,  and  the  gastric  contents  were  not 
examined.  After  she  left  the  nursing  home  late  in  May  her 
own  doctor  did  not  see  her  again  until  the  end  of  November. 
The  responsibility  for  this  lay  entirely  with  the  patient ;  and  by 
the  end  of  November  an  inoperable  neoplasm  had  developed. 
Had  her  doctor  been  seeing  her,  a  malignant  stomach  would 
have  been  diagnosed  probably  in  July,  when  operative  inter- 
position would  have  held  out  a  prospect  of  radical  cure.  In  all 
stomach  cases  which  do  not  yield  readily  to  treatment  it  is 
essential  to  examine  the  gastric  contents  for  free  HCl,  and 
this  would  certainly  have  been  done  in  this  case  had  she  been 
under  observation.  When  free  HCl  is  absent  the  suspicion 
of  malignancy  should  never  be  airily  set  aside  on  account  of 
the  patient's  age.  As  has  been  already  insisted  on,  a  case 
of  hypochlorhydria  which  proves  refractory  to  treatment  is 


148  THE   STOMACH 

probably  malignant.  So  strong  is  this  probability  that  the 
onus  of  proof  lies  with  the  contrary  opinion. 

Case  29b. — Miss  S.,  aged  31,  was  seen  by  me  on  the 
4th  December,  1920,  in  consultation  with  her  medical 
attendant.  The  history  was  that  in  July  she  began  to 
feel  her  digestion  to  be  out  of  order.  She  had  a  holiday 
of  some  weeks  in  the  month  of  August,  which  did  not 
benefit  her.  Appetite  was  very  poor,  she  had  a  definite 
dislike  to  food,  and  took  very  little.  On  returning  home 
she  resumed  her  ofiice  duties,  and  continued  them  until 
quite  recently,  although  she  was  living  mainly  on  liquid 
nourishment  and  taking  very  little.  Her  doctor  saw  her 
shortly  before  I  saw  her,  and  found  a  lump  in  the  epigastrium, 
which  varied  in  position  and  sometimes  could  not  be  felt. 
When  I  saw  her  the  "  lump  "  was  clearly  the  pylorus,  and 
the  history,  characterized  by  stomach  discomfort,  not  pain, 
continued  repulsion  to  food,  and  loss  of  flesh,  left  no  doubt 
in  one's  mind  that  this  was  another  malignant  stomach, 
near  the  pylorus,  at  a  very  early  age,  A  test  breakfast 
the  following  morning  showed  entire  absence  of  free  HCl. 

Professor  Caird  operated  and  was  able  not  only  to 
perform  a  gastro-enterostomy,  but  to  do  a  gastrectomy. 
The  disease,  which  was  close  to  the  pylorus,  was  quite  cir- 
cumscribed and  there  is  considerable  ground  for  hope  that 
it  may  not  recur.  The  patient  stood  the  operation  well 
and  made  an  uninterrupted  recovery. 

Remarks. — The  long  history  in  this  patient  of  gastric 
disturbance,  with  not  only  loss  of  appetite,  but  positive 
dislike  of  and  repulsion  to  food,  was  very  ominous.  The 
absence  of  symptom  suggestive  of  chronic  gastric  ulcer 
was  another  important  point.  The  "  lump,"  which  changed 
its  position,  was  palpable  sometimes,  and  could  not  be 
found  at  other  times,  is  characteristic  of  the  pylorus  ;  some- 
times in  spasm  contraction  and  palpable,  at  other  times 
relaxed  and  not  palpable.  No  doctor  had  seen  this  patient 
until  her  ordinary  medical  attendant  saw  her,  and  fully 
investigated  her  condition.  It  is  at  this  early  stage  that  it 
is  so  important  to  diagnose  malignancy  in  this  viscus. 


Section  11.— THE  PYLORUS  AND  DUODENUM 
CHAPTER   XIII 

INTRODUCTORY 

We  now  pass  to  the  consideration  of  matters  concerning  the 
pylorus  and  the  duodenum  as  they  appear  to  me  as  a 
physician. 

We  can  never  understand  this  important  region  unless 
we  begin  at  the  right  point,  and  here,  as  is  so  commonly  the 
case  in  medicine,  the  right  point  means  functional  disturbance. 
The  functional  disturbance  in  this  region  round  which 
controversy  lingers  is  hyperchlorhydria  ;  what  symptoms 
are  to  be  referred  to  it,  and  which  belong  to  gross  anatomical 
lesion  ?  It  is  not  necessary  again  to  argue  that  there  is  a 
morbid  condition  called  hyperchlorhydria.  It  is  sufficient 
to  state  that  to  me  it  is  a  clinical  entity  ;  presumably  an  acid 
dyscrasia,  the  manifestation  of  a  metabolic  diathesis  on  the 
part  of  the  individual.  The  acceptance  of  this  proposition 
is  the  starting  point  of  any  further  knowledge  we  may  acquire 
concerning  certain  important  conditions  met  with  at  the 
pylorus  or  in  the  duodenum.  On  this  as  a  foundation  we 
may  at  least  hope  to  build  securely  :  we  may  have  to  un- 
build and  to  rebuild,  but  so  long  as  we  come  back  to  it  we 
may  hope  that  ultimately  we  shall  find  the  building  secure. 

An  attack  of  hyperchlorhydria  may  be  determined  by 
such  diverse  causes  as  chill,  fatigue,  worry,  or  dietetic  error. 
Once,  however,  we  accept  the  existence  of  the  clinical  entity, 
and  that  it  is  a  diathetic  error,  we  are  prepared  for  other 
phenomena  presenting  themselves. 

Recurrence  of  Attacks  is  one  of  these,  in  one  person  deter- 
mined by  worry,  as  surely,  and  perhaps  more  surely,  than 

149 


150  THE   PYLORUS   AND   DUODENUM 

in  another  it  is  determined  by  dietetic  error.  The  story 
of  these  recurrences  can  often  be  traced  back  for  many  years, 
as  we  trace  back  a  rheumatic  or  other  well-recognized 
diathesis.  In  one  of  my  cases  there  was  a  history  running 
back  for  forty  years. 

Pain  as  a  Symptom. — Assuming  then  the  existence  of  the 
condition,  let  us  next  consider  its  symptom — pain  or  dis- 
comfort. This  symptom  comes  on  one  to  two  hours  or 
longer  after  a  meal ;  it  comes  on  after  most  if  not  all  of  the 
protein  food  has  been  digested  and  has  left  the  stomach. 
The  pain  associated  with  duodenal  ulcer  comes  on  under 
similar  circumstances  and  presumably  from  the  same  cause. 
It  is  evidently  not  caused  by  the  mere  passage  of  well- 
digested  gastric  contents  over  the  surface  of  the  ulcer  which 
causes  pain,  but  the  spasm  of  involuntary  muscle  when  the 
gastric  contents  attain  a  high  degree  of  acidity.  The 
phenomenon  of  pain  coming  on  with  a  considerable  interval 
between  its  onset  and  the  last  meal  is  common  to  both 
conditions,  and  in  interpreting  the  phenomenon  we  must 
begin  with  our  knowledge  of  hyperchlorhydria,  and  our 
experience  of  how  it  can  be  controlled  and  checked  ;  that 
is  our  first  step,  and  unless  it  is  firm  and  secure  the  second 
cannot  be  so,  although,  even  then,  a  secure  foothold  is, 
happily  for  some  of  our  patients,  not  impossible. 

The  Etiology  of  Acute  Ulcer. — ViQien  we  consider  the 
etiology  of  acute  ulcer  no  one  questions  the  association 
of  hyper-acidity  with  acute  gastric,  p3doric,  or  duodenal 
ulcer ;  it  would  almost  appear  to  be  established  that  hyper- 
acidity precedes  ulcer  and  in  some  way  leads  to  it.  If  we 
look  at  this  subject  a  little  more  closely  we  shall  find  that  the 
latest  experimental  work  has  shown  that  acute  ulcer  is 
readily  produced  by  rendering  a  bit  of  stomach  wall  bloodless 
by  means  of  the  local  injection  of  adrenalin.  Local  blood- 
vessel spasm  is,  in  fact,  all  that  is  required  to  lead  to  acute 
ulcer.  We  may  carr}'  our  mental  vision  further  and  picture 
to  ourselves  that  when  there  is  irritative  spasm  of  the 
musculature  of  stomach,  pylorus,  or  duodenum,  one  limited 
area  may  be  so  bloodless  that  necrosis  results,  followed  by 


HEALING   OF   ACUTE   ULCER  151 

speedy  solution  of  tissue  by  digestive  fluids,  with  the  result 
that  an  acute  ulcer  is  formed.  If  we  regard  the  question 
in  this  way  the  marvel  is  that  ulcer  in  these  parts  is  not  more 
common  than  it  is. 

Whatever  picture  we  form  of  the  mode  of  production 
of  such  acute  ulcers,  it  seems  certain  that  they  can  be 
produced  suddenly,  that  is  rapidly,  and  without  having  been 
preceded  by  symptoms  of  digestive  disturbance  sufficient 
to  have  given  rise  to  any  marked  discomfort.  One  hears 
of  cases  of  perforated  duodenal  ulcer  occurring  in  the  middle 
of  the  night,  with  but  trifling  preceding  digestive  disturbance 
to  help  the  diagnosis.  Such  acute  cases  cannot  be  regarded 
as  preventable,  and  the  medical  man's  responsibility  begins 
and  ends  with  prompt  diagnosis  and  the  prompt  summoning 
of  surgical  skill.  That  hyperchlorhydria  may  be  the  pre- 
cursor of  ulcer  makes  it  all  the  more  important  to  recognize 
the  disorder  of  function  and  to  treat  it  promptly  and 
efficiently. 

Perforation. — When  ulcer  is  present,  the  accompanying 
thought  is,  commonly,  perforation,  with  all  its  dreaded  results. 
Yet  perforation  either  of  gastric  or  of  duodenal  ulcer  is  not 
common.  If  I  take  my  own  experience  I  find  that  I  have 
seen  many  cases  of  ulcer  but  comparatively  few  of  gastric 
or  of  duodenal  perforation,  and  my  experience  is  not  at 
variance  with  the  experience  of  others. 

Healing  of  Acute  Ulcer. — The  next  point  that  I  would 
draw  attention  to  is  that  pyloric  and  duodenal  ulcers 
heal,  probably  as  readily  as  gastric  ulcer,  if  the  conditions 
are  made  favourable  to  their  doing  so.  In  support  of  this 
statement  let  me  remind  you  that  the  diagnosis  of  recent 
duodenal  ulcer  is  based,  in  the  first  instance,  on  the  presence 
of  altered  blood  in  the  stools.  The  advent  of  severe  pain 
two  hours  or  so  after  a  meal  is  not  pathognomonic  of  duodenal 
ulcer  ;  but  such  pain  associated  with  melsena  has  been  long 
regarded  as  justifying  a  diagnosis  of  duodenal  ulcer.  I  have 
seen  many  such  cases,  I  shall  here  only  mention  one  of 
them ;  a  man  sent  with  a  diagnosis  of  duodenal  ulcer  to 
my  ward  by  one  of  my  surgical  cofleagues,  with  a  view  to 


152  THE   PYLORUS  AND   DUODENUM 

having  his  general  condition  improved  before  being  operated 
on.  This  patient  had  pain  coming  on  after  every  meal  and 
persistent  melaena.  I  treated  him  as  I  would  have  treated 
a  case  of  hyperchlorhydria,  with  the  result  that  his  pain 
rapidly  disappeared,  and  the  bleeding  stopped,  even  occult 
blood  not  being  demonstrable.  He  was  soon  allowed  a 
more  liberal  dietary  and  his  general  condition  greatly 
improved.  He  felt  so  well  that  he  did  not  quite  see  why  he 
should  undergo  an  operation,  and  my  surgical  colleague 
was  not  prepared  to  press  it.  He  therefore  went  home  but 
got  instructions  about  his  diet  and  habits  generally,  and  was 
advised  to  return,  if  pain  or  melsena  returned.  He  had  not 
reappeared  by  the  time  I  ceased  to  be  in  charge  of  wards. 

I  merely  want  to  emphasize  the  propositions  that  duodenal 
ulcer  may  heal,  and  that  the  danger  of  perforation  may  be 
greatly  exaggerated,  and  excite  quite  unwarrantable  alarm. 
I  need  not  multiply  cases  ;  this  case  is  selected  for  evident 
reasons — the  diagnosis  was  not  mine,  although  I  entirely 
agreed  with  it ;  it  was  based  upon  the  clinical  phenomena 
mentioned ;  when  these  phenomena  disappeared  and 
digestive  comfort  and  vigour  were  restored  the  idea  of  the 
continuance  of  the  ulcer  was  not  entertained.  Without  this 
logical  method  internal  diagnosis  would  cease  to  be  a  science, 
and  become  an  art  of  occult  divination.  Mere  assertive 
insistance  that  the  ulcer  is  still  there  is  outside  the  region 
of  scientific  medicine.  Diagnosis  is  based  on  phenomena  ; 
and  accurate  diagnosis  upon,  first,  the  power  of  determining 
the  presence  or  absence  of  certain  phenomena  ;  and,  secondly, 
on  the  faculty  of  arranging  the  order  and  of  estimating  the 
value  of  the  facts  ascertained.  If  phenomena  disappear 
we  are  bound  to  consider  that  their  cause  has  disappeared. 
If  the  phenomena  reappear,  the  cause  has  presumably 
reappeared. 

Pyloric  and  Duodenal  Scar. — I  next  draw  attention  to 
the  existence  of  pyloric  and  duodenal  scar.  I  take  these 
two  together,  as  they  give  rise  to  similar  phenomena  as 
regards  the  stomach  ;  and  I  hope  to  show  that  the  gastric 
phenomena  which  can  be   demonstrated  are  of    valuable 


EFFECT   OF   SCAR  AND   NARROWING        153 

assistance  in  deciding  the  question  as  to  what  treatment  the 
patient  ought  to  undergo. 

In  considering  the  phenomena  of  this  stage  we  are  again 
thrown  back  on  our  initial  contentions  regarding  hyper- 
chlorhydria.  By  accepting  these  we  form  a  working 
conception  of  what  occurs.  We  find  a  reasonable  explanation 
of  the  phenomena  present. 

Hyperchlorh3'dria,  as  has  been  stated  already,  commonly 
precedes  ulcer.  It  is  moreover  a  recurring  condition.  The 
addition  of  duodenal  ulcer  to  the  hyperchlorhydria  can 
frequently  be  dated  to  some  one  particular  attack  of  hyper- 
chlorhydria, definitely  more  severe,  or  more  prolonged,  than 
other  attacks,  and  not  infrequently  giving  a  distinct  history 
of  melaena.  Such  an  attack  may  date  back  many  years  ; 
but  between  that  time  and  the  present  there  may  be  a  history 
of  many  lesser  attacks.  These  lesser  attacks  give  a  history 
of  h;yperchlorhydria,  but  tend  to  run  into  prolonged  gastric 
discomforts,  the  reason  for  which  is  readily  found. 

Hsrperchlorhydria  and  Gastric  Antonicity. — One  of  the 
results  of  hj-perchlorhydria  is  gastric  atonicity  with  sagging 
of  the  lower  border  of  the  stomach.  When  the  hyperchlor- 
hydria is  treated  effectively  this  atonicity  is  recovered  from  ; 
but  with  the  recurrence  of  the  hyperchlorhydria  there  is  a 
return  of  the  sagging.  With  repeated  recurrence  of  the 
former  the  sagging  becomes  more  marked  and  becomes  more 
chfhcult  to  correct.  This  is  the  course  that  might  have  been 
predicted  :  hyperchlorhydria,  pyloric  spasm,  atonic  gastric 
waU,  sagging  of  lower  border  aU  seem  an  orderlj^  pathological 
sequence  and  such  we  may  take  them  to  be.  That  the 
ultimate  result  should  be  such  as  is  frequently  found  cannot 
cause  surprise  when  we  know  how  little  is  thought  of  attacks 
of  so-called  "  indigestion  "  and  how  httle  effort  is  made  to 
correct  the  symptoms. 

Effect  of  Scar  and  Narrowing. — We  may,  however,  carry 
this  a  point  further.  And  it  is  this  :  when  there  is  a  scar 
at  the  pylorus  or  in  the  duodenum,  and  especially  if  there  be 
even  slight  narrowing  of  outlet  or  of  duodenum,  the  atonicit}^ 
with  its  consequent  sagging,  becomes  more  marked  with  each 


154  THE   PYLORUS    AND   DUODENUM 

successive  attack  of  hyperchlorhj^dria  and  becomes  more 
difficult  to  correct  b}^  ordinary  means.  The  difficulty  at 
this  stage  hes,  not  in  restraining  the  hyperchlorhydria, 
but  in  getting  the  stomach  completely  to  empty  itself. 
This  is  only  effected  by  toning  up  the  atonic  lower  border,  and 
by  bringing  the  axis  of  the  stomach  into  correct  relation  to 
the  channel  of  exit,  which  is,  of  course,  the  pyloric  outlet. 
This  difficulty  becomes  greater  as  years  pass,  until  a  time 
arrives  when  the  discomfort  has  become  almost  intolerable, 
and,  on  examination,  the  merest  tyro  can  determine  the 
existence  of  a  dilated  and  prolapsed  viscus. 

The  point  I  msh  to  make  is  that  here  there  is  added  to 
S3^mptoms  of  pure  hyperchlorhydria  symptoms  due  to 
retention  of  a  residuum  of  the  food  taken.  The  retention  is  the 
result  of  the  sagging  of  the  lower  border  to  begin  with. 
Following  upon  this  the  pyloric  antrum  becomes  more 
dilated,  and,  in  the  recumbent  position,  the  right  border  of 
the  stomach  is  carried  more  and  more  to  the  right  of  the 
mesial  plane.  The  dilatation,  with  this  extension  to  the 
right,  is  easy  of  determination.  I  have  found  that  when  it 
occurs  the  stomach  overlies  the  pylorus,  that  is,  the  pylorus 
is  behind ;  so  that  when  the  abdomen  is  opened,  it  cannot 
be  seen  until  the  stomach  is  pulled  aside. 

It  seems  to  me  that  the  determination  of  what  for 
convenience  I  have  called  "  the  right  border  of  the  stomach," 
is  of  great  help,  especially  when  dealing  with  cases  where  there 
is  doubt  as  to  the  necessit}^  of  having  a  gastro-enterostomy 
done. 

When  the  pylorus  is  overlain  by  the  stomach  in  the 
manner  indicated,  there  is  usually  an  organic  difficulty  at  the 
pyloric  outlet.  In  the  majority  of  cases  this  overlying  only 
occurs  when  there  is  a  scar  or  some  other  anatomical  cause 
of  difficult}^  The  overlying  is  often  of  determining  import- 
ance. I  have  not  seen  it  in  the  spasm  and  sagging  due  solely 
to  hyperchlorh}'dria.  Certainly  in  all  cases  of  long  standing 
I  have  invariably  found  the  right  border  far  beyond  the 
middle  line,  as  the  accompanying  cases  and  figures  show. 
The  only  doubtful  point  is  as  to  whether  it  can  always  be 


EFFECT   OF   SCAR   AND   NARROWING        155 

taken  as  pointing  to  the  existence  of  scar  or  of  narrowing. 
I  am  none  the  less  assured  that  the  position  of  the  right 
border  is  of  much  practical  significance.  I  can  go  this  far 
that,  if  medical  treatment  does  not  remove  the  overlying, 
the  only  relief  obtainable  is  by  means  of  a  gastro-enterostomy. 
In  such  cases  it  is  found  that  there  is  a  scar,  or  some  pyloric 
narrowing. 

It  is  important  to  state  that  when  cases  of  the  kind  are 
seen  early  enough  and  their  character  is  recognized,  the 
stomach  position  may  be  restored.  It  requires,  however, 
careful  dietetic  and  other  measures  ;  and  even  after  restora- 
tion has  been  effected,  comparatively  moderate  indiscretion 
may  reproduce  the  condition.  I  followed  a  very  instructive 
case  of  this  kind  for  three  years  and  at  last  advised  a  gastro- 
enterostomy. At  the  pylorus  there  w^as  a  scar  but  not,  I 
fancy,  any  greater  narrowing  than  had  existed  for  years. 
The  ulcer  which  had  left  the  scar  dated  back  some  seven 
years  or  more. 

Another  patient  whom  I  saw  more  recently,  presented 
such  stomach  displacement  as  has  been  referred  to.  This 
patient  had  been  operated  on  a  year  before  for  perforated 
duodenal  ulcer.  Without  hesitation  gastro-enterostomy 
was  advised,  as  I  was  of  opinion  that  the  stomach  condition 
was  to  be  attributed  to  duodenal  narrowing  following  upon 
the  previous  operation,  and,  therefore,  irremediable  by 
medical  measures.  The  operation  was  agreed  to,  and  the 
conditions  anticipated  were  found  to  be  present.  A  gastro- 
enterostomy was  entirely  successful  and  enabled  the  patient 
to  pursue  an  arduous  life  with  fuU  vigour.  In  this  patient 
the  development  of  gastric  symptoms  had  been  progressive 
and  were,  when  I  saw  him,  grievously  interfering  with  his 
capacity  to  carry  through  his  daily  duties. 

If,  on  the  other  hand,  to  attain  improvement,  without 
operation,  it  is  necessary  to  put  a  patient  to  bed,  and  to  use 
dietetic  and  other  expedients,  I  am  not  sanguine  of  obtain- 
ing permanent  well-being ;  for  experience  shows  that  such 
cases  readily  relapse. 

The  following  tracings  of  stomachs  such  as  have  been 


156 


THE   PYLORUS   AND   DUODENUM 


described  were  prepared  as  follows.  The  position  of  the 
stomach  is  marked  out  on  the  surface  of  the  trunk  :  a  sheet 
of  tracing  paper  is  placed  over  the  trunk  and  the  position 
marked  of  themammse,  of  the  costal  margins,  of  the  umbilicus, 
of  the  anterior  superior  iliac  spines,  and  of  the  pubes  ;  then 
the  stomach  outline  is  traced.  The  tracing  is  photographed 
and  from  that  the  figures  were  prepared.  The  advantage 
of  this  method  is  that  each  figure  shows  the  exact  relation 
of  the  stomach  to  the  anatomical  points  mentioned.  True 
relations  are  by  this  means  maintained. 

Tracings  of  four  stomachs  are  given  as  samples  of  many 
and  as  they  constituted  the  evidence  on  which  stress  was 
laid  when  advising  operation.  The  accuracy  of  the  tracings 
was  constantly  checked  on  the  operating  table.  In  this 
way  confidence  was  established  in  the  accuracy  of  the 
methods  which  have  been  described. 

Case  30. — J.  P.,  aged  29,  had  a  gastric  history  of  12 
years'  duration.    Eight  years  ago  he  had  black  stools.    Three 

years  ago  he  was  free  of 


© 


® 


symptoms  for  a  year. 
Symptoms  returned  two 
years  ago,  and  at  that 
time  he  vomited  black 
material.  He  had  the 
power  of  vomiting  when 
he  wished.  He  was  in 
hospital  during  the  pre- 
vious August  and  Sep- 
tember without  receiving 
material  benefit.  He  was 
re-admitted  the  following 
May.  The  annexed  is  the 
outline  of    his   stomach. 

Mr.  Miles  did  a  gastro-enterostomy.     There  was  cicatricial 

thickening   at   the  pylorus.     The  patient  did  well  and  was 

relieved. 

Case  31. — L.  L.,  aged  39,  had  a  history  of  stomach  trouble 

for  seven  years.     For  eighteen  months  he  had  no  treatment, 


Fig.  15. — Case  30. 


ILLUSTRATIVE    CASES  157 

then  he  began  to  take  bi-carbonate  of  soda.  The  main 
symptom  was  uneasiness  coming  on  an  hour  after  food. 
There  was  occasional  vomiting,  which  gave  relief.  The 
symptoms  got  more  pronounced,  uneasiness  becoming  severe, 
pain  beginning  an  hour  after  food.  For  six  months  the 
pain  had  not  only  been  very  severe  but  almost  constant. 
Vomiting  was  frequent  and  two  months  ago  he  vomited 
half  a  pint  of  reddish-brown  fluid,  but  there  had  been 
no  melaena.  He  had  lost  5  st.  in  weight  in  eighteen 
months  having  fallen  from  15  st.  to  10  st.     Fig.  16  is  the 

©  ®  @  © 


<5U 


r\  /\ 


r\ 


Fig.  16. — Case  31.  Fig.  17.— Case  32. 

stomach  tracing.  Mr.  Miles  found  cicatricial  thickening 
at  the  pylorus  causing  so  much  stenosis  that  the  fingers 
would  not  meet.  A  gastro-enterostomy  was  done  and  the 
patient  made  a  speedy  and  admirable  recovery. 

Case  32. — J.  D.,  aged  45,  was  admitted  on  the  29th  of  July. 
There  was  a  history  of  what  was  thought  to  be  gall-stone  colic 
in  the  previous  February.  He  had  gastric  symptoms  since 
the  middle  of  June,  consisting  of  a  feeling  of  fullness  and 
discomfort  in  the  right  hypochondrium.  There  was  no 
vomiting  or  nausea.  The  bowels  were  constipated.  There 
was  no  melsena.  He  was  only  taking  about  one-third  of 
his  ordinary  diet.     There  was  no  free  HCl.    Figure  17  is  the 


158 


THE   PYLORUS   AND   DUODENUM 


stomach  tracing.  Mr,  Stnithers  found  the  pylorus  was  the 
seat  of  what  was  thought  to  be  a  cicatricial  thickening  with 
so  much  stenosis  that  it  would  not  admit  the  little  finger. 
A  gastro-enterostomy  was  done.  The  patient  did  well,  but 
looking  back  on  this  case  additional  experience  suggests 
that  the  condition  at  the  pylorus  was  malignant. 

Case  33. — J.  M.,  aged  43,  was  admitted  with  a  history 
of  gastric  trouble  reaching  back  for  eighteen  years.     It  began 


© 


© 


with  pain  coming  on  three  to 
four  hours  after  taking  food 
and  relieved  by  food.  These 
symptoms  lasted  for  three 
months.  Ten  years  ago  he 
had  a  similar  attack  which 
lasted  for  six  months.  Five 
years  ago  he  sought  advice 
at  the  Infirmary,  and  was 
sent  away  with  a  prescription. 
A  fortnight  later,  when  out 
driving,  he  felt  sick  and  ten 
minutes  later  vomited  a  large 
quantity  of  dark  -  brown 
material.  Nine  months  ago 
pain  came  on  again,  and  has  continued  off  and  on  since 
then,  and  for  the  last  three  weeks  he  has  been  off  work  on 
account  of  it.  Mr.  Struthers  did  a  gastro-enterostomy  and 
the  patient  made  a  good  recovery.  The  above  is  the  tracing 
of  this  stomach. 


eU 


Fig.  18. — Case  33. 


CHAPTER   XIV 

DUODENAL   ULCER 

Diagnosis. — The  diagnosis  of  duodenal  ulcer  may  be  made 
very  easily  but  it  may  present  considerable  difficulty. 

Pain. — The  outstanding  symptom  is  pain  in  the  upper 
half  of  the  abdomen  in  the  middle  line  between  the  xiphi- 
sternum  and  the  umbilicus  or  to  the  right  of  it ;  it  may 
radiate  over  the  hepatic  region,  through  to  the  lumbar 
region,  or  upwards  to  behind  the  scapula.  The  pain  comes 
on  two  hours  or  more  after  food  ;  it  may  continue  until  the 
stomach  is  empty,  or  until  the  next  meal  is  taken,  when 
it  is  temporarily  relieved  by  the  closure  of  the  pylorus  and 
the  lowering  of  the  acidity  of  the  gastric  contents.  In 
severe  cases  the  pain  is  constantly  present,  but  is  most 
severe  some  time  after  taking  food.  In  the  symptom  of 
pain  ulcer  closely  resembles  hj^perchlorhydria  ;  but  from 
this  symptom  alone  the  diagnosis  of  ulcer  ought  not  to  be 
made.  In  the  great  majority  of  patients  the  symptom 
means  hyperchlorhydria. 

Melaena. — The  next  sign  of  ulcer  is  melcena.  When 
this  occurs  coupled  with  such  pain  as  has  been  referred  to, 
the  diagnosis  of  ulcer  is  established.  The  diagnosis,  how- 
ever, ought  not  to  lead  to  panic,  as  it  seems  to  do  in  the 
minds  of  some  members  of  the  profession  as  well  as  of  the 
laity.  The  ulcer  if  a  recent  one  will  heal  under  favourable 
conditions.  If  gastric  symptoms  have  for  some  time 
preceded  melaena  the  stomach  will  give  the  indications  of 
sagging  which  have  already  been  fully  described,  and  *  the 
right  border  will  be  found  to  the  right  of  the  middle  line. 

159 


i6o  THE   PYLORUS   AND   DUODENUM 

Absence  o£  Meleena. — But  ulcer  may  be  present  with,  a 
total  absence  of  a  history  of  melaena.  In  cases  of  this  kind 
pain  continues  to  be  the  prominent  symptom,  varying  in 
degree  ;  influenced  by  the  kind  and  quantity  of  food  taken  ; 
ameliorated  up  to  a  certain  point  by  anti-hyperchlorhydric 
remedies,  but  not  usually  wholly  removed.  On  examination 
there  is  found  to  be  stomach  sagging  and  dilatation  with 
the  right  border  much  to  the  right  of  the  middle  line  and 
often  right  over  to  the  costal  margin. 

Haemorrhage  is  thus  an  inconstant  sign  of  ulcer  ;  its 
presence  may  be  pathognomonic,  whilst  its  absence  is  not 
negative. 

Pain  and  Sagging. — Persistent  pain,  not  in  the  sense  of 
being  constantly  present,  but  constantly  reasserting  itself, 
along  with  abundant  secretion  of  hydrochloric  acid,  giving 
evidence  of  much  free  HCl  whenever  the  gastric  contents 
are  tested,  and  stomach  sagging  and  dilatation,  with  the  right 
border  to  the  right,  are  as  absolute  proofs  of  ulcer,  which  is 
not  yielding  and  will  not  yield  to  medical  treatment,  as  are 
available  to  clinical  medicine.  The  long-standing  cases 
may  have  a  history  of  many  attacks  of  melsena,  and  may 
ultimately  die  of  severe  haemorrhage  with  haematemesis 
as  well  as  melaena.  On  the  other  hand  a  chronic  ulcer  may 
ultimately  lead  to  almost  complete  occlusion  of  the  duodenum 
from  the  thickening  occurring  round  it,  thereby  rendering 
the  provision  of  a  new  channel  for  the  passage  of  food 
essential  if  life  is  to  be  continued,  and  yet  there  may  be 
no  history  of  melaena. 

Symptoms  Masked. — In  some  cases  there  is  no  history  of 
melaena  ;  but  there  is  pain  coming  on  at  varying  intervals 
after  food  ;  there  is  a  sagged  and  dilated  stomach,  which 
takes  long  to  empty  itself  of  the  previous  meal ;  always 
much  free  HCl ;  and  yet  the  pain  can  be  so  controlled  as  to 
be  negligible  even  while  the  patient  is  on  a  liberal  and 
mixed  diet.  A  case  of  this  kind  is  given  further  on.  The 
uncertainty  of  this  case  was  settled  ultimately  by  the 
appearance  of  melaena.  It  is  of  much  importance  to  know 
that  2inder  treatment  the  symptoms  may  he  masked  in  some 


ILLUSTRATIVE   CASES  i6i 

cases  so  as  to  make  it  temporarily  doubtful  as  to  the  necessity 
for  surgical  interposition.  This  point  will  be  more  fully 
dealt  with  under  the  cases  which  are  given  to  illustrate  the 
different  aspects  duodenal  ulcer  presents. 

Illustrative  Cases 

Pain  :  Recurring  Helena  :  Fatal  Hemorrhage 

Case  34. — J.  M.,  aged  58,  had  suffered  from  his  stomach 
for  some  years,  the  history  being  typical  of  hyperchlorhydria. 
In  1914  he  had  melaena,  and  this  recurred  from  time  to  time. 
He  suffered  a  great  deal  from  pain.  His  medical  attendant 
thought  the  ulcer  had  healed  as  there  had  not  been  melaena 
for  some  time.  A  sudden  profuse  bleeding  with  haema- 
temesis  and  melaena,  during  which  the  patient  fainted,  was 
followed  by  others,  of  which  he  died  in  1919.  The  ulcer 
was  a  chronic  one  with  thickened  edges.  The  patient 
was  from  the  outset  strongly  opposed  to  operation. 

Persistent  Pain  :  Dilated  Stomach  :  Operation  : 
Complete  Recovery 

Case  35. — David  D.,  aged  31,  clerk,  was  admitted 
to  the  Royal  Infirmary  on  the  9th  September,  1914, 
The  complaint  was  pain  in  the  stomach  at  night  for  the 
previous  six  months. 

History. — About  nine  years  before  admission  he  had  his  first 
attack  of  pain  in  the  upper  part  of  the  abdomen.  The  pain 
was  sharp  and  stabbing  in  character  and  "  doubled  him  up." 
It  came  on  about  two  or  two  and  a  half  hours  after  food, 
and  was  worst  at  night.  The  attack  passed  off  in  about  a 
week  under  treatment.  For  two  years  he  was  free  from 
pain.  He  then  had  a  second  attack  of  the  same  kind,  which 
lasted  for  two  weeks.  Since  then  he  had  had  occasional 
attacks  of  pain,  but  they  were  of  short  duration  and  never 
severe.  Seven  months  before  (February,  1914),  the  third 
severe  attack  occurred.  Pain  came  on  about  two  hours 
after  food,  and  continued  to  the  next  meal,  which  gave 
relief.     The  pain  was  of  a  dull,  burning  character.     It  was 

II 


i62  THE   PYLORUS   AND   DUODENUM 

always  worst  at  night,  from  lo  p.m.  to  3  a.m.  ;  it  was  in  the 
upper  part  of  the  abdomen  and  to  the  right  of  the  middle  line 
and  went  through  to  the  left  shoulder-blade.  Since  February 
the  pain  had  been  practically  constant  except  for  a  day  now 
^  and  then,  and  it  had  got  gradually 

worse,  so  much  so  that  he  could 

not  work  or  sleep.     He  had  never 

..•••'•••-.,,        vomited  ;    and  only   occasionally 

^.,.'*''  \    had  heart-burn   and  water-brash. 

..'''*'  i    The  bowels  were  regular  up  till  a 

•     month   ago    and    he    never    had 

black  motions.  He  had  lost  nearly 

''*-..  ®U  .,-•*'**  2   St.  since   the   beginning  of   the 

"""'"  year.     Lately    he    had   lived    on 

Fig.  19.  ~'  ^ 

Benger's  food,  chicken  or  veal 
tea,  toast  and  charcoal  biscuits.  Greasy  and  vegetable  soups 
were  avoided,  as  they  always  caused  severe  pain.  Bicarbonate 
of  soda  gave  temporary  reHef,  and  taking  food  also  gave 
rehef.     There  had  been  flatulence. 

Examination.  —  The  abdomen  was  regular  in  outhne 
and  moved  freely  on  respiration.  There  was  no  rigidity 
but  there  was  slight  tenderness  over  an  area  2  ins.  above 
the  umbilicus  and  2  ins.  from  the  middle  Hne.  The  stomach 
was  enlarged  and  splashing  to  the  right  of  the  middle  Hne 
as  shown  in  the  tracing,  Fig.  19. 

On  the  nth  September  the  report  was  of  pain  the 
previous  night  and  of  having  vomited  16  ozs.  before  break- 
fast. The  vomit  was  Hght -green  in  colour,  and  consisted 
almost  entirely  of  clear  fluid  with  some  starch  and  fat 
globules  ;   it  showed  much  free  HCl. 

On  the  15th  September  a  test  breakfast  showed  much 
free  HCl. 

On  the  1 6th  September  he  was  X-rayed  six  hours  after 
a  bismuth  meal,  when  a  large  amount  of  the  meal  was  still 
seen  to  be  in  the  stomach  but  some  had  reached  the  caecum. 
Twenty-four  hours  later  all  the  bismuth  was  at  the  csecum. 

On  the  1 8th  September  he  was  transferred  to  Professor 
Caird,  who  found  a  duodenal  ulcer  just  beyond  the  pylorus, 


ILLUSTRATIVE   CASES  163 

and  performed  a  gastro-enterostomy.  He  returned  to  my 
ward  on  the  30th  September  and  was  discharged  on  the 
14th  October  feeling  quite  well.i 

Much  Pain,  no  Helena,  Large  Gastric  Dilatation  : 
Operation  :  Complete  Restoration 

Case  36. — C.  R.,  aged  62,  suffered  some  years  ago 
from  h3'perchlorhydria,  from  which  he  had  recovered  under 
appropriate  treatment.  The  symptoms  returned  and 
gradually  became  more  pronounced  until  a  time  came  when 
no  medicine  gave  much  relief  and  what  relief  was  obtained 
was  merely  temporary.  Diet  had  to  be  restricted  to  the 
simplest  and  blandest  of  foods,  and  these  were  taken  in 
small  quantity  because  everything  caused  pain.  He  neces- 
sarily lost  weight  and  found  his  work  very  trying  during 
the  years  of  war,  and  only  his  great  fortitude  and  endurance 
enabled  him  to  keep  to  his  post.  When  pain  was  at  its 
worst  he  emptied  the  stomach  by  vomiting,  which  was 
easily  done  by  touching  the  pharynx.  The  stomach  was 
dilated  and  its  contents  could  be  splashed  to  the  right 
costal  margin.  This  patient  was  also  much  opposed  to 
operation  but  ultimately  consented.  Professor  Caird  saw 
him  and  the  operation  was  done  by  Mr.  Wilkie.  An  ulcer 
was  found  an  inch  or  more  to  the  distal  side  of  the  pylorus, 
the  floor  of  which  was  so  flimsy  that  it  gave  way  when 
handled ;  after  that  was  secured  a  gastro-enterostomy 
was  performed.  The  X-ray  examination  showed  the  stomach 
to  be  very  large  and  atonic  with  no  appearance  of  the  bis- 
muth passing  the  pylorus.  For  various  reasons  this  case 
was  specially  observed,  and  the  X-ray  examinations  were 
found  to  confirm  fully  the  observations  made  in  advance 
of  the  examinations.  The  position  and  size  of  the  stomach 
in  the  recumbent  position  was  verified  ;  it  was  also  seen 
how  in-  this  position  part  of  the  stomach  was  flattened  against 
the  spine  while  the  bismuth  lay  to  left  and  right  of  it.  This 
phenomenon  has  been  already  referred  to  as  explaining  the 

1  The  notes  of  this  case  were  made  by  my  House  Physician,  Dr.  G.  M.  Brown. 


i64  THE   PYLORUS   AND   DUODENUM 

failure  to  get  a  succussion  wave  unless  the  stomach  is  ver}- 
full,  while  a  gurgle  or  splash  can  often  be  obtained  to  left 
and  right  of  the  spine.  These  phenomena  were  very  pro- 
nounced in  this  patient  and  frequently  noted. 

The  operation  was  highly  satisfactory  in  its  results. 
Pain  was  at  once  relieved.  The  patient  rapidly  regained 
the  weight  which  had  been  lost,  and  also  his  former  strength 
and  vigour. 

Gastric  Symptoms  for  Twenty-three  Years  :  Hyper- 
CHLORHYDRiA  :  DuoDENAL  Ulcer  :  Great  Stenosis  : 
Operation  Successful 

Case  37. — Mr.  W.,  aged  38,  had  suffered  from  his 
stomach  for  many  years.  The  trouble  began  when  he  was 
15  years  old.  He  clearly  remembered  that  pain  used 
to  come  on  two  hours  after  taking  food,  and  that  it  was 
relieved  by  taking  food.  Before  that  time  he  "  could 
digest  anything."  The  S3anptoms  were  not  always  present  ; 
they  came  and  went  and  between  the  attacks  he  "  could 
eat  anything  without  discomfort."  The  attacks  gradually 
became  more  frequent,  more  severe  and  more  prolonged. 
Taking  bicarbonate  of  soda  used  to  relieve,  but  this  largely 
lost  its  effect.  The  dose  he  took  was  three-quarters  of  a 
teaspoonful.  He  had  much  flatulence  both  upwards  and 
downwards.  The  bowels  were  fairly  regular,  but  he  occa- 
sionally took  cascara  or  Gregory's  powder  and  more  recently 
paraffin.  He  said  he  "  had  suffered  more  than  anybody 
would  beheve."  His  ordinary  medical  attendant  had  not, 
he  stated,  ever  suggested  to  him  that  anything  more  could 
be  done  for  him  than  was  being  done.  Owing  to  change  of 
residence  he  changed  his  doctor  and  fell  into  hands  that 
recognized  the  necessity  for  further  treatment. 

Examination. — He  was  of  fair  complexion,  of  good 
colour,  but  very  spare  and  there  was  no  subcutaneous  fat. 
I  saw  him  about  one  and  a-half  to  two  hours  after  he  had 
taken  a  meal  consisting  of  fish  and  milk  pudding.  On 
inspection  of  the  abdomen  the  outline  of  the  stomach  was 
visible  and  its  peristaltic  movements  were  easily  stimulated 


ILLUSTRATIVE   CASES 


165 


and  visible  through  the  thin  parietes.  Splashing  was 
readily  obtained  and  the  succussion  wave  felt  to  the  right 
costal  margin.  Fig.  20  is  a  copy  on  a  reduced  scale  of 
the  outline  of  the  stomach  made  at  this  time.  He  was  sent 
into   a  nursing  home  for 

the  night.     I  saw  him  six     ©  ® 

hours  after  the  midday 
meal  referred  to,  and 
found  the  stomach  much 
as  it  had  been  earlier,  but 
not  quite  so  full.  A 
sample  removed  by  the 
tube  showed  much  free 
HCl.  In  the  morning  he 
was  X-rayed  by  Dr.  Hope 
Fowler  and  seen  also  later 
in  the  day.  This  examina- 
tion confirmed  the  opinion 
that  there  was  great  py- 
loric stenosis.  The  X-ray 
plate  taken  in  the  re- 
cumbent position  corre- 
sponded exactly  with  Fig. 

20.  The  accuracy  of  the  outHne  was  tested  on  the  screen 
and  on  the  plate  and  showed  the  complete  correctness 
of  the  tracing  in  regard  to  fundus,  the  level  of  the  inferior 
border,  and  the  position  of  the  right  border.  The  only 
discrepancy  was  the  lesser  curve,  owing  to  the  stomach 
having  been  fuller  when  the  tracing  was  made  than  when 
the  X-ray  plate  was  taken.  Operation  by  Mr.  Jar  dine  was 
most  successful. 


0u 


Fig.  20.— Case  37.  Stomach  tracing, 
showing  great  ptosis  of  greater 
curve. 


Scar  on  Lesser  Curve  of  Stomach  near  Pylorus, 

ANOTHER     IN     THE     DuODENUM     NEAR     THE     PyLORUS, 

AND  Pyloric  Stenosis 

Case   38.— William  G.,   aged  40,   was   admitted   to  the 
Royal  Infirmary  on  the  9th  September,  1914. 

History. — Since  boyhood  he  had  suffered  from  a  "  weak 


i66  THE   PYLORUS   AND   DUODENUM 

stomach "  and  had  to  be  cautious  in  diet.  Fat  meat, 
porridge,  and  potatoes  were  avoided,  as  they  gave  rise  to  a 
feeling  of  distension.  Six  weeks  before  admission  he  began  to 
have  pain  after  ever}'  meal.  It  came  on  about  an  hour  after 
food  and  got  gradually  worse  until  relief  was  obtained  by 
vomiting.  Pain  was  not  related  to  any  particular  kind  of 
food,  even  water  or  milk  induced  it.  At  first  he  was 
able  to  take  Benger's  food  mthout  pain  or  vomiting  as  a 
result,  but  for  five  weeks  he  vomited  after  everything  he 
took.  On  several  occasions  after  much  retching  the  vomit 
had  been  Uke  coffee-grounds.  He  never  vomited  red  blood. 
The  vomit  was  very  bitter  and  "  burnt  the  back  of  the 
throat."  The  motions  had  never  been  black.  The  bowels 
were  constipated.  Since  the  previous  \vinter  he  had  lost  over 
3  St.  in  weight.  He  had  not  suffered  from  heart-burn  but 
^ ^  occasionally     from     water- 

brash  after  eating  oat-cakes. 
Examination.  —  Teeth 
were  good  and  the  gums 
were  healthy.  Tongue  was 
moist    and    shghtly   furred 

\.^  -•'''  in    centre.      Appetite   was 

®  U  good  but  he  could  not  retain 

Fig.  21. — Case  38.  food.      The    stomach    was 

much  enlarged,  as  shown  in 
the  tracing,  Fig.  21  ;  there  was  slight  tenderness  about  the 
normal  position  of  the  pylorus  but  nowhere  else.  On  the  loth, 
the  day  after  admission,  he  had  pain  about  midday  and 
16  ozs.  were  withdrawn  from  the  stomach,  consisting  mainly  of 
the  food  he  had  taken.  There  was  much  free  HCl.  On  the 
nth  he  had  no  pain,  but  the  stomach  was  easily  splashed. 
On  the  13th  pain  returned,  which  was  removed  by  mth- 
drawing  the  stomach  contents.  On  the  14th  he  was  examined 
by  X-rays  in  the  erect  position,  when  the  stomach  was  shown 
as  low  as  the  right  iliac  fossa.  Examination  six  hours  "after 
the  bismuth  meal  had  been  given  showed  that  none  of  the 
meal  had  left  the  stomach.  Professor  Caird  operated  on 
the  1 8th  and  did  a  gastro-enterostomy.     He  found  marked 


A   RELIC   OF   THE   NEAR   PAST  167 

pyloric  stenosis,  an  old  scar  on  the  lesser  curve  of  the  stomach, 
and  another  scar  in  the  duodenum  near  the  pylorus.  The 
patient  made  an  excellent  recovery  and  was  relieved  of  all 
his  previous  miseries. 

A  Relic  of  the  Near  Past  : 

Gastric  Symptoms  for  Forty  Years  :    Stomach  Tube 

Daily  for  Seventeen  Years  :   Operation  :   Cured 

Case  39. — John  H.,  aged  60,  was  admitted  to  the  Royal 
Infirmary  on  the  21st  October,  1910.  The  history  of 
his  stomach  symptoms  covered  a  period  of  forty  years. 
At  the  age  of  twenty  he  began  to  suffer  from  a  gnawing 
pain  which  came  on  about  two  hours  after  meals  but  it  was 
not  severe.  It  often  began  about  midnight  and  would 
last  until  he  got  up  and  took  some  baking  soda.  The  pain 
came  on  about  two  hours  after  breakfast  and  continued 
until  the  midday  meal,  the  taking  of  which  gave  rehef ; 
two  hours  later  the  pain  returned  and  was  again  put  away 
by  taking  supper.  Pain  was  also  removed  by  taking 
bicarbonate  of  soda.  A  year  later  he  had  another  attack 
which  lasted  about  a  week.  Up  to  the  age  of  forty  he 
suffered  off  and  on  in  this  way.  At  the  age  of  forty  the 
attacks  became  worse  and  blood  was  passed  per  rectum 
on  at  least  two  occasions  and  he  was  unfit  for  work  for 
months.  He  also  vomited  stuff  like  coffee-grounds  on  one 
or  two  occasions.  He  was  admitted  to  the  Royal  Infirmary 
suffering  from  severe  pain  and  was  treated  by  having  the 
stomach  washed  out.  This  relieved  him,  and  he  had  evi- 
dently been  taught  to  use  the  tube,  for  he  continued  to  use 
it  almost  daily  for  seventeen  years  before  he  was  admitted 
to  my  ward  in  October,  1910.  The  stomach  tube  had  ceased 
to  relieve  him  and  vomiting  had  supervened.  On  admission 
the  stomach  was  found  to  be  much  dilated  as  shown  in  the 
tracing,  p.  168,  Fig.  22.  There  was  no  tenderness  on 
palpation  anywhere  in  the  abdomen.  There  was  no  visible 
peristalsis.  The  patient  was  transferred  to  Mr.  Miles  on 
the  24th,  and  on  the  28th  a  gastro-enterostomy  was  done. 
An  old  duodenal  ulcer  was  present  with  so  much  thickening 


i68  THE  PYLORUS  AND   DUODENUM 

around  it  that  the  duodenum  was  almost  completely  occluded. 
Recovety  was  rapid  and  the  patient  left  the  infirmary 
reheved  of  his  miseries  and  continued  so  when  last  heard 
of  long  after  the  operation. 

Remarks. — This  case  is  given  as  a  connecting  link  before 
the  present  and  the  recent  past.  The  treatment  of  the 
patient   for   gastric   dilatation   and   vomiting   b}^   stomach 

lavage  was  as  far  as 
medicine  had  developed 
at  the  time.  The  discovery 
b}^  surgery  that  the  abdo- 
men could  be  safely  opened 
and  its  \dscera  freely 
_ , ,  .••'  handled  has  led  us  to  the 

"■•• ••■""  diagnostic    accuracy    now 

attainable    and    to    a  re- 
finement in  operative  pro- 
'"•  ^  cedure  that  leaves  but  little 

more    to    ^^ish    for.     The 
,.      , .,.  case     is     instructive      as 

Fig.  22. — Case  39.     L  umbilicus.  . 

illustratmg  a  history  of 
recurring  hyperchlorhydria  for  twenty  j^ears  ;  then  duodenal 
ulcer  being  added,  rendering  him  unfit  for  work  until  the 
S3'mptoms  were  controlled  for  many  years  by  using  the 
stomach  tube  daily. 

Causes  of  Unsatisfactory  Operation  Results 

The  result  of  gastro-enterostomy  in  stomach  and  duodenal 
cases  is  eminenth*  satisfactor\'  in  cases  properly  selected 
and  in  which  the  operation  has  fulfilled  certain  requirements. 
The  failures,  or  apparent  failures,  have  been  a  small  propor- 
tion of  the  total  and  they  can  be  placed  in  definite  groups. 

A.  Ineflficient  Drainage. — A  striking  example  of  this  has 
been  given  in  Case  12,  Chapter  IX.,  where  the  only  possible 
explanation  of  the  first  opening  being  a  failure,  and  the 
second  one  an  immediate  success,  must  have  been  a  matter 
of  drainage.     Other  cases  occur  where  discomfort  has  not 


CAUSES   OF   UNSATISFACTORY   RESULTS      169 

been  entirely  removed ;  and  where  it  will  be  found  that 
there  is  a  residuum  of  food  in  a  portion  of  sagged  stomach 
which  is  below  the  gastro-enterostomy  opening.  Such  a 
residuum  usually  contains  much  free  HCl.  In  one  patient 
with  this  condition  there  occurred  from  time  to  time  attacks 
of  nausea  and  loss  of  appetite  due  to  reflux  from  the  duode- 
num through  the  pylorus,  and  containing  bile. 

B.  Continued  Haemorrhage  or  Pain. — ^This  is  met  with 
in  cases  of  gastric  or  duodenal  ulcer  when  the  ulcer  has  not 
been  dealt  with  directly  by  the  surgeon.  The  behef  that  a 
gastro-enterostomy  will  lead  to  the  heahng  of  gastric  or 
duodenal  ulcer  in  all  cases  is  contradicted  by  experience. 
That  being  the  position  the  writer  fails  to  understand  why 
ulcer  in  either  region  should  not  be  dealt  with  directly 
whenever  practicable.  Recurring  haemorrhage  from  a 
duodenal  ulcer,  after  gastro-enterostomy,  is  a  most  unsatis- 
factory sequel ;  and  continued  pain  from  a  gastric  ulcer 
is  highly  disappointing  to  patient  and  physician. 

C.  Recurrence  of  Hj^perchlorhydria  or  Appearance  of  Hsrpo- 
chlorhydria. — Either  of  these  conditions  may  make 
their  appearance  ;  and  there  may  be  no  evidence  to  show 
that  it  is  anything  more  than  a  functional  perturbation 
such  as  occurs  where  there  has  been  no  operation.  That 
gastro-enterostomy  is  to  cure  an  acid  dyscrasia  is  perhaps 
an  unreasonable  expectation.  Certain  it  is  that  some 
cases  require  from  time  to  time  to  have  treatment  appli- 
cable to  hyperchlorhydria.  Hypochlorhydria  is  much  less 
frequent,  but  it  is  met  with,  and  when  it  is  recognized  it 
can  be  successfully  treated  by  the  means  emplo3-ed  for  the 
counteracting  of  that  defect.  I  have  seen  this  emerge 
eight  years  after  a  gastro-enterostomy. 

D.  Spastic  Stomach. — In  some  cases  continued  discom- 
fort seems  to  be  due  to  an  almost  spastic  contraction  of  the 
stomach  wall  interfering  with  the  gastro-enteric  opening, 
practically  closing  it,  so  that  a  residue  of  contents,  in  a 
highly  acid  medium,  is  retained,  and  is  evidently  the  cause 
of  the  discomfort. 


CHAPTER   XV 

SILENT   OR   MASKED   DUODENAL   ULCER  :    THE   EXPLANATION 
OF   PAIN    AND   THE   CONTROL   OF   PAIN 

Reference  has  already  been  made  to  the  alleviation  of  the 
symptoms  of  duodenal  ulcer.  In  the  first  of  the  two  f  ollo^^ing 
cases  the  symptoms  were  not  only  alleviated  but  were  kept 
in  abeyance  by  the  regular  use  of  anti-h37perchlorhydria 
treatment,  so  completely  that  the  existence  of  ulcer  was 
obscured  until  a  profuse  melaena  proved  its  presence.  The 
possibiKty  of  thus  masking  the  symptoms  must  not  be 
lost  sight  of  and  it  must  be  recognized  that  it  adds  to  the 
difficulty  of  diagnosis  when  there  is  no  history  of  melsena. 
This  recurring  masking  of  symptoms  by  treatment  occurs 
in  cases  of  undoubted  ulcer.  I  know  a  patient  who  has  had 
recurring  attacks  of  pain  ^^dth  melsena  for  years  and  whose 
attacks  have  so  far  been  overcome  by  a  few  da3'S  of  very 
careful  dieting  and  the  free  use  of  belladonna  and  bicar- 
bonate of  soda.  He  is  strongly  and  persistently  opposed 
to  operation. 

Pain  :  Dilated  Stomach  :  Pain  removed  by  Treatment  : 
Mel^na  :    Operation  :    Duodenal  Ulcer 

Case  40. — Mr.  H.,  Indian  Government  servant,  aged  39, 
was  sent  to  me  on  the  20th  June.  The  history  given  was  that 
he  had  suffered  from  stomach  pain  off  and  on  for  the  past 
five  years  or  so.  The  pain  had  been  intermitting,  attacks 
occurring  every  three  or  four  months.  During  the  last 
3''ear  they  had  become  more  frequent  and  more  severe.  The 
pain  was  usually  worst  about  eight  o'clock  at  night,  but  was 

170 


MASKED   DUODENAL   ULCER  171 

relieved  by  taking  dinner,  and  there  was  no  pain  during  the 
night.  Bicarbonate  of  soda  relieved  the  pain.  There  was 
troublesome  and  somewhat  obstinate  constipation.  The 
tongue  was  clean  and  moist.  The  general  condition  was 
good,  although  there  had  been  some  loss  of  weight.  On 
examination  of  the  abdomen  the  stomach  was  splashed  to 
the  right  costal  margin  ;  there  were  fseces  in  the  transverse 
colon  ;  there  was  no  tenderness  at  the  caecal  region  on  careful 
and  detailed  palpation.  He  was  seen  a  week  later,  three 
hours  after  lunch,  when  the  stomach  was  in  much  the  same 
condition,  and  a  specimen  withdrawn  by  means  of  the  tube 
showed  abundant  free  HCl.  He  was  treated  from  the  outset 
for  hyperchlorhydria,  and  he  faithfully  carried  it  out  during 
the  succeeding  months.  He  was  not  seen  again  until  he 
returned  to  Edinburgh,  seven  months  later.  He  looked 
better  and  had  kept  himself  free  of  pain  although  not 
restricting  his  diet  to  any  marked  extent.  On  examination 
the  stomach  was  found  to  be  as  large  as  before,  with  the  right 
border  at  the  right  costal  margin.  The  constipation  had 
continued  obstinately  troublesome  in  spite  of  phenol 
phthalein,  cascara,  and  taraxacum.  The  condition  was  so 
unsatisfactory  that  he  was  again  X-rayed.  The  examination 
suggested  the  possibility  of  a  duodenal  ulcer  retaining  some 
bismuth.  He  was  advised  to  go  into  a  nursing  home  for 
observation,  and  he  was  again  seen  by  Professor  Caird. 
The  morning  of  the  day  on  which  we  together  saw  him  he 
had  a  large  melsena,  which  removed  any  doubt  there  may 
have  been  as  to  the  probability  of  ulcer.  He  was  operated 
on  in  a  few  days,  when  the  presence  of  the  ulcer  was  further 
confirmed.     He  made  a  good  recovery. 

Pain  :    its  Cause  and  its  Control 

This  case  provides  a  striking  illustration  of  the  control 
of  pain  even  when  duodenal  ulcer  is  present.  It  may  be 
used  as  a  peg  on  which  to  hang  some  remarks  and  reflexions 
which  have  an  important  bearing  on  the  question  of  the 
existence  of  duodenal  ulcer  in  certain  cases.     In  the  fore- 


172  THE  PYLORUS  AND  DUODENUM 

going  case  there  had  been  a  period  of  fully  three  years  during 
which  there  had  been  recurring  attacks  of  hyperchlorhydria  ; 
but,  for  a  year  or  more,  attacks  became  more  frequent,  more 
severe  and  less  tractable.  There  was  no  history  of  melaena. 
When  seen  by  me  there  was  evidence  of  marked  sagging  of 
the  stomach  as  shown  by  the  right  border  being  at  the  costal 
margin.  Complaint  of  pain  was  not  pronounced,  nor  indeed 
at  all  definite,  but  at  this  stage  the  patient  tended  to  belittle 
his  symptoms.  By  means  of  belladonna  and  bicarbonate 
of  soda  he  kept  himself  free  of  serious  discomfort  for  seven 
months  while  he  was  visiting  friends  in  different  places  in 
England.  When  again  seen  his  general  condition  had 
appreciably  improved.  Yet  there  was  persistent  delay  in 
stomach  emptying  :  four  and  a  half  hours  after  a  moderate 
midday  meal  the  stomach  could  still  be  splashed  to  the  right 
costal  margin.  The  stomach  had  not  lost  any  of  the  sagging 
that  was  found  seven  months  before.  The  question  arose 
whether  there  might  be  a  congenitally  narrowed  pylorus. 
He  was  again  X-rayed  and  no  such  narrowing  was 
demonstrable  and  the  stomach  emptied  the  bismuth  in 
good  time.  In  this  business  of  emptying  it  has  to  be  insisted 
on  very  strongly  that  the  emptying  of  a  bismuth  meal  must 
not  be  taken  as  representing  what  happens  when  ordinary 
food  is  taken.  The  position  of  the  right  border,  determined 
by  succussion,  or  by  it  and  auscultation,  is  the  only  reliable 
means  of  determining  whether  the  stomach  has  passed  on 
or  is  unduly  retaining  the  food  which  has  been  taken  into 
it.  In  this  case,  there  was  undue  retention.  The  retention 
could  not  be  due  to  failure  of  gastric  digestion,  because 
it  was  already  known  that  the  patient  was  an  active 
acid  secretor.  Moreover,  he  knew  that  he  could  coun- 
teract his  digestive  pain  by  the  free  use  of  an  alkali, 
and  I  had  encouraged  him  to  use  the  alkali  freely  for  this 
purpose. 

This  is  not  the  description  of  a  unique  case.  The  effect 
of  treatment,  when  it  is  pushed  far  enough,  frequently  has 
this  effect  on  the  symptom  of  pain  in  the  class  of  case  we  are 
considering.     It  is  during  this  period  that  healing    of  an 


PAIN:   ITS  CAUSE  AND   ITS   CONTBOL        173 

ulcer  will  take  place  if  it  is  to  heal.  The  phenomenon  in 
this  case,  as  in  others,  throws  a  clear  light,  I  venture  to 
hold,  on  the  symptom  of  pain  when  ulcer  is  present.  In  this 
case  pain  was  not  cured,  if  we  may  speak  of  the  cure  of  a 
symptom,  it  was  merely  kept  in  abeyance,  certainly  for 
months.  And  yet  the  ulcer  was  there.  There  was  no 
anatomical  cause  of  obstruction  at  the  pylorus,  and  gastric 
peristalsis  was  fairly  good.  Although  there  was  delay,  the 
stomach  contents  finally  passed  through,  and  had  never  been 
rejected  by  vomiting.  It  may  be  safely  assumed  that  the 
activity  of  acid  secretion  varied  from  time  to  time,  and  that, 
when  pain  came  on,  the  secretion  was  more  active,  but  could 
be  counteracted  and  controlled  by  bicarbonate  of  soda. 
This  not  only  relieved  the  pain  but  allowed  the  gastric 
contents  to  pass  into  the  duodenum  without  causing 
pain. 

The  explanation  of  this  seems  to  me  to  be  as  follows. 
The  pain  in  hyperchlorhydria  is  due  to  spasm  of  the  pyloric 
musculature,  but,  at  least  when  ulcer  is  present,  instead  of 
this  being  a  stimulus  arising  from  the  proximal  side  of  the 
pylorus,  it  arises  from  the  distal  side,  that  is  the  duodenal 
side,  and  is  the  result  of  some  of  the  super-acid  contents 
trickUng  into  the  duodenum.  That  the  presence  of  an 
ulcer  in  the  duodenum  should  accentuate  this  backward- 
acting  reflex  can  hardly  be  doubted.  Certain  it  is  that  the 
mere  passage  of  gastric  contents  over  a  duodenal  ulcer  does 
not  necessarily  or  always  cause  pain.  They  require  to  be 
unduly  acid  ;  which  is  to  be  interpreted  as  free  HCl.  This 
brings  the  condition  into  interesting  relationship  to  the 
phenomenon  referred  to  earlier  as  the  gastric  phase  of  pyrosis, 
described  by  Roberts,  but  which  the  writer  believes  to  be  a 
pyloric  phenomenon. 

Accepting  this  explanation  to  be  correct,  it  makes  it 
necessary  to  treat  cases  of  hyperchlorhydria  with  intelligent 
vigour  so  as,  in  the  first  place,  haply  to  prevent  the  for- 
mation of  ulcer.  If  ulcer  has  formed  it  may  heal,  If, 
however,  pain  is  only  kept  in  abeyance  by  treatment, 
and   if     there    is    stomach    sagging    with    retention,    the 


174  THE   PYLORUS  AND   DUODENUM 

presumption  is  that  there  is  ulcer,  although  there  has  not 
been  melcena. 

Dilated  and  Sagged  Stomach  :  No  Pain  :  No 
hemorrhage  i  diagnosis,  "  pyloric  difficulty  "  i 
Operation  :    Duodenal  Ulcer 

Case  41. — ]\Ir.  B.,  aged  27,  had  served  his  country  during 
the  war,  but  was  latterly  interned  in  Holland,  where  he  was 
poorlj-  fed  and  had  tr3dng  experiences.  When  he  returned 
home  in  October,  1818,  he  was  run  down  physically  and 
nervously.  He  was  sent  to  me  in  the  end  of  October,  1919. 
Four  and  a  half  months  before  I  saw  him  he  began  to  suffer 
from  intense'stomach^discomfort  with  flatulence  and  consti- 
pation.    He  also  suffered  from  sleeplessness. 

Examination  showed  him  to  be  very  lean.  The  tongue  was 
clean.  The  abdomen,  examined  two  hours  after  breakfast, 
revealed  nothing  abnormal  on  inspection  save  great  leanness 
of  its  wall.  On  examination  the  stomach  fundus  was  found 
to  be  large  ;  its  greater  curve  was  at  the  umbilicus  ;  and  its 
right  border  two  inches  to  the  right  of  the  middle  line.  This, 
of  course,  was  in  the  recumbent  position  and  was  determined 
by  percussion,  succussion,  and  succussion  combined  with 
auscultation.  A  specimen  removed  from  the  stomach  by 
means  of  the  tube  showed  the  previous  meal  to  be  well 
broken  up.  There  was  much  free  HCl.  He  was  given 
belladonna  and  valerian  before  meals  and  bicarbonate  of 
soda  to  be  taken  after  food  when  discomfort  began.  A 
laxative  pill  consisting  of  phenol  phthalein,  cascara,  and 
taraxacum  was  given  for  the  constipation. 

This  treatment  was  continued  more  or  less  steadily  until 
I\Iarch,  when  I  saw  him  again  after  an  interval  of  two  months. 
His  general  condition  had  improved,  but  the  gastric  symptoms 
had  varied  ;  the  most  definite  sj'mptom  obtained  was  that 
stomach  discomfort  became  worse  if  he  attempted  to  walk 
much.  Examination  of  the  abdomen  at  different  hours 
showed  no  change  in  the  condition  of  the  stomach.  He 
could  make  it  splash  audibly  at  any  time,  and  I  never  found 
it  empty.     He  could  make  it  splash  before  breakfast,  having 


MASKED  DUODENAL  ULCER       175 

swallowed  neither  food  nor  fluid  since  8  o'clock  the  previous 
night.     There  was  an  entire  absence  of  complaint  of  pain  ; 
he  would  not  allow  that  it  was  more  than  "  discomfort," 
but  it  worried  him  and  it  was  acting  as  a  drag  upon  recovery 
from  his  neurasthenia.     I  had  had  him  X-rayed  in  November 
by  Dr.  Hope  Fowler  as  I  thought  he  might  have  a  congenitally 
narrow  pylorus  which  only  asserted  its  presence  after  his 
experiences  in  Holland.     The  bismuth,  however,  passed  out 
of  the  stomach  in  reasonably  good  time,  whereas  ordinary 
food  did  not  do  so.     My  surgical  colleague  Mr.  Wilkie  saw 
the  patient  with  me /and  Dr.  Fowler  again  X-rayed  him  with 
the    special    object    of    determining    what    evidence    such 
examination  would  give  of  pyloric  difficulty  and  the  nature 
of  the  difficulty.     That  there  was  pyloric  hindrance  seemed 
to  me  to  be  beyond  doubt.     At  this  second  examination 
it  was  seen  that  the  duodenal  cap  was  slow  in  appearing, 
was  small  in  size,  and  that  the  stem  connecting  it  with  the 
antrum   was   small.      The   pyloric   channel   could   not    be 
satisfactorily  brought  out  by  manipulation  or  by  change 
of    position.     It    was    agreed   that    pyloric    difficulty   was 
present,  and  that  it  would  be  dealt  with  in  accordance  with 
what  should  be  found.     Duodenal  ulcer  was  not  excluded, 
although   the   symptoms   did   not    definitely   point   to   its 
presence,  but  it  seemed  the  only  alternative  to  a  congenital 
stenosis.     The   differentiation  of   these   was   an     academic 
point,  so  far  as  the  patient  was  concerned,  for  whichever 
it  was  required  to  be  dealt  with  surgically.     The  abdomen 
was  opened,  when  it  was  found  that  there  was  no  stenosis, 
but   an  ulcer  in  the  first  part   of  the  duodenum,   which 
had    not     produced     any    appreciable     narrowing    of    the 
duodenum. 

Remarks. — ^This  case  illustrates  what  may  be  termed 
"  silent  duodenal  ulcer  "  in  so  far  that  pain  was  not  definitely 
present.  It,  however,  further  illustrates  what  has  been  dealt 
with  fully  in-  a  previous  chapter,  namely,  the  great  value  of 
determining  the  position  of  the  right  border  of  the  stomach. 
It  also  shows  that  bismuth  is  expelled  from  the  stomach  in 
much  shorter  time  than  an  ordinary  meal.     Although  there 


176  THE   PYLORUS  AND   DUODENUM 

was  an  absence  of  pain  and  of  haemorrhage,  the  persistent 
sagging  of  the  stomach  with  the  right  border  to  the  right 
and  retention,  showed  that  there  was  pyloric  difficulty  which 
was  not  yielding  to  medicinal  treatment  and  required  surgical 
interposition  for  its  relief. 


SectioxX  hi.— the  intestinal   TPvACT 
CHx\PTER   XVI 

ENTEKOPTOSIS  :    SPLANCHNOPTOSIS    OR   VISCEROPTOSIS 

The  term  Enteroptosis  means  that  there  is  ptosis  or  dropping 
of  nitestine.  Splanchnoptosis  or  Visceroptosis  means  that 
there  is  dropping  of  aU  the  abdominal  organs,  not  only 
stomach  and  intestine,  but  also  of  the  liver  and  kidneys. 
The  bladder  is,  of  course,  excluded,  although  it  may  be  pressed 
upon  by  the  weight  of  the  other  hollow  viscera.  The 
differentiation  is  not  above  criticism,  for  it  suggests  a  separa- 
tion of  conditions  which  are,  in  part  at  least,  always  associated. 
In  gastroptosis,  for  instance,  the  ptosis  is  not  confined  to 
the  stomach,  it  always  carries  with  it  ptosis  of  the  trans- 
verse colon  ;  so  definitely  is  this  the  case  that  when  the 
position  of  the  lower  limit  of  the  stomach  is  determined 
it  is  certain  that  the  position  of  the  transverse  colon  is  at 
least  lower  than  that,  and  that  the  coils  of  the  small  intestine 
are  correspondingly  lowered.  While  the  transverse  colon 
is  thus  lowered  its  hepatic  and  splenic  flexures  may  remain 
fixed  approximately  in  their  normal  position  so  that  the 
transverse  portion  is  U-shaped,  an  acute  angle  being  there- 
by formed  at  both  flexures.  In  other  cases  both  flexures 
may  be  much  below  their  normal  position  as  is  seen  in 
Figs.  27  and  28.  Another  very  important  point  which 
has  to  be  determined  in  aU  cases  of  gastroptosis  is  tJie  position 
of  the  pylorus  and  its  relation  to  the  axis  of  the  stomach. 
In  some  cases  the  pylorus,  although  it  ma}-  be  considerably 
to  the  right  of  and  below  its  normal  position,  is  not  lowered 

177  12 


178  THE   INTESTINAL  TRACT 

in  proportion  to  the  lowering  of  the  stomach.  When 
this  occurs  it  can  be  readily  understood  that  the  stomach 
has  great  difficulty  in  emptying  and  may  be  quite  unable 
to  expel  its  contents  into  the  duodenum,  especially  in  the 
upright  posture,  and  that  this  leads  to  long  retention  of 
food  in  the  stomach.  This  retention  leads  to  exhaustion 
of  the  musculature  and  to  consequent  greater  dilatation 
and  sagging  of  the  lower  border  of  the  viscus.  In  other 
cases  the  position  of  the  pylorus  is  relatively  as  low  as  the 
axis  of  the  stomach.  When  this  condition  is  present  the 
stomach  empties  satisfactorily,  and  progressive  atony, 
dilatation,  and  sagging  does  not  take  place.  This  latter 
condition  is  probably  congenital,  for  it  is  associated  wdth  a 
long,  straight  aorta  and  a  heart  long,  narrow,  and  low  in 
position.  The  liver  and  diaphragm  are  also  lov/  in  position. 
Cases  of  this  description  are  not  uncommon,  and  it  is  usu'ally 
so  easy  to  make  out  that  the  stomach  is  below  the  level  ot 
the  umbiUcus  that  the  opinion  may  be  formed  that  the  patient 
requires  gastro-enterostomy.  This  opinion  is  stiU  more 
readily  arrived  at  if  the  patient  has  an  intercurrent  attack 
of  gastric  disturbance  at  the  time  when  seen  and  examined. 
Such  cases  are  not  exempt  from  functional  gastric  disorder 
and  if  this  has  existed  for  some  time  there  may  have  been  a 
loss  of  weight  which  further  tends  to  lead  to  a  wrong  diag- 
nosis. Operation  in  cases  of  this  description  is  probably 
one  of  the  causes  which  has  led  to  doubt  in  some  minds  as 
to  the  value  of  a  highly  valuable  operation  when  performed 
in  properly  selected  cases.  It  is  here  assumed  that  entero- 
ptosis  and  visceroptosis  are  congenital  conditions,  although 
they  may  become  more  pronounced  as  life  advances.  In 
women  there  is  a  temptation  to  attribute  it  primarily  to 
tight  lacing,  but  its  occurrence  in  men  throws  doubt  upon 
this  interpretation.  The  cases  I  have  seen  have  been  mostl}- 
in  persons  in  middle  life.  They  belong  to  the  lean  type, 
who  never  put  on  fat,  and  are  small  or  moderate  eaters. 
They  are  usually  seen  when  suffering  from  an  intercurrent 
disturbance  of  gastric  function,  associated  as  that  often 
is  with  atonicity  and  dilatation,  or  with  a  definite   attack 


t 


Fig.  23. — Case  42.  Shows  the  upright  position  of  the 
stomach  with  the  pyloric  portion  hook-shaped  below 
the  level  of  the  umbilicus. 


d 

^K  .*^                                                     J^ 

|^^|h 

^»    ^mA 

^^^^S. 

!»    m 

Fig.  24. — Same  case,  4  hours  later  ;  bismuth  all  out  of 
stomach. 

[To  face  pa^e  178. 


Fig.  2^. — Same  case,  24  hours  later  ;  showing  position 
of  hepatic  flexure. 


1 JG.  2',.- — Siime  case,  4.S  hours  after;  showing  low  position 
of  both  flexures. 

[To  jace  page  i7q. 


VISCEROPTOSIS   IN  THE  FEMALE  SEX      179 

of  hyperchlorhydria.  The  intercurrent  disturbance  accen- 
tuates the  coarser  evidences  of  displacement  and  dilatation 
and  readily  leads  to  error  in  advising  surgical  interposition. 
In  enteroptosis  when  the  stomach  empties  readily  a  gastro- 
enterostomy can  do  no  good  and  will  probably  do  much 
harm. 

The  following  cases  are  examples  of  the  condition. 


Visceroptosis  in  the  Female  Sex 

Case  42  (Mrs.  R.). — Figs.  23  to  26  show  the  position 
of  the  stomach  and  colon  in  this  patient.  As  in  all  such 
cases,  there  was  much  discomfort,  a  weary  sense  of  dragging 
and  constipation.  The  position  of  the  stomach  in  the 
upright  position  is  shown  in  Fig.  23.  The  pyloric  portion 
of  the  viscus  is  seen  to  be  below  the  level  of  the  umbilicus. 
Notwithstanding  this  the  organ  emptied  in  good  time. 
Fig.  24  shows  that  the  bismuth  had  completely  passed  out 
of  it  in  four  hours.  Fig.  25,  taken  twenty-four  hours  after 
the  bismuth  was  given,  shows  it  heaped  up  in  the  caecal 
region.  It  is,  however,  to  be  noted  that  the  bismuth  is 
not  only  in  the  caecum,  but  in  what  represents  the  ascending 
colon,  the  hepatic  flexure,  and  the  first  part  of  the  transverse 
colon  ;  the  hepatic  flexure  is  seen  to  be  below  the  level  of 
the  iliac  crest.  Fig.  26  shows  the  position  of  the  bismuth 
at  the  end  of  forty-eight  hours.  Some  of  the  bismuth  has 
passed  along  the  transverse  colon  to  the  splenic  flexure, 
which,  like  the  hepatic  flexure,  is  below  the  level  of  the  iliac 
crest.  This  is  a  good  example  of  enteroptosis  in  a  patient 
with  visceroptosis.  The  slow  progress  of  the  bismuth 
represented  the  constipation.  As  there  was  no  undue 
retention  of  food  in  the  stomach  all  thought  of  using  a 
gastro-enterostomy  was  excluded  ;  and  as  there  was  no 
known  method  of  tacking  up  the  abdominal  viscera,  she  was 
measured  for  a  light  abdominal  corset  and  the  constipation 
was  corrected  bj^  means  of  a  suitable  laxative.  The  lady 
became  pregnant  and,  as  happens  in  such  circumstances, 
the  enlarging  uterus  served  as  an  adiiiirable  support  to  the 


i8o  THE   INTESTINAL  TRACT 

dropped  viscera.  After  the  child  was  born  the  abdominal 
corset  was  adjusted,  and  the  action  of  the  bowels  was 
attended  to.  Her  condition  has  continued  to  be  most 
satisfactory. 

Visceroptosis  in  a  Patient  who  had  not  worn  Corsets 

Case  43. — Mrs.  M.,  aged  58,  had  borne  six  children. 
She  suffered  from  pains  radiating  all  over  the  chest  and  often 
referred  to  the  precordia.  She  suffered  from  the  conse- 
quences of  a  lacerated  perineum  which,  although  healed, 
had  left  an  enfeebled  anal  sphincter  and  a  tendency  to 
piles.  The  uterus  was  reported  as  normal.  She  had  to  be 
careful  of  her  feeding  owing  to  abdominal  discomfort,  but 
the  view  was  strongly  expressed  that  her  symptoms  were 
all  to  be  attributed  to  the  state  of  the  heart  and  circulation. 
She  had  been  seen  by  several  doctors  reputed  to  be  specialists. 
A  doctor  in  America  attributed  her  symptoms  to  a  curvature 
in  the  lower  cervical  region  and  sent  her  to  an  osteopath 
for  treatment.  Another  doctor  told  her  she  was  suffering 
from  "  spurious  angina  pectoris,"  the  patient  resenting 
the  word  spurious  as  her  pains  were  very  real.  Another 
specialist  said  she  was  suffering  from  toxaemia  from  the 
piles.  On  examination  I  found  heart  and  vessels  perfectly 
sound.  The  abdominal  wall  was  thin,  fatless,  and  very  lax. 
The  stomach  was  very  low  in  position  and  the  right  kidney 
was  loose  and  half  of  it  projected  beyond  the  ribs.  There 
was  no  doubt  that  the  condition  was  a  pronounced  viscero- 
ptosis, but  there  was  no  evidence  of  food  being  unduly 
retained  in  the  stomach.  The  condition  was  explained 
to  the  patient  and  her  husband,  and  they  agreed  to  a  complete 
X-ray  examination  in  confirmation  of  the  diagnosis.  The 
condition  had  not  before  been  even  suggested  to  them.  The 
X-ray  examination  in  the  upright  position  showed  that  the 
stomach  emptied  in  good  time  in  spite  of  its  low  position.  Its 
inferior  border  was  only  two  fingers'  breadth  above  the  pubes, 
both  the  hepatic  and  splenic  flexures  were  much  below  their 
normal  positions,  and  the  right  kidney  was  partly  in  the 
iliac  fossa.     It  is  almost  needless  to  say  that  this  condition 


VISCEROPTOSIS   IN  THE  MALE   SEX        i8i 

of  abdominal  viscera  was  sufficient  to  account  for  all  the 
symptoms  complained  of.  The  patient  had  in  earlier  life  been 
verj'  strong  and  vigorous  and  the  only  available  explanation 
of  the  condition  was  that  the  abdominal  wall  had  been 
allowed  to  remain  lax  after  the  various  confinements.  She 
had  never  worn  corsets.  Surgical  interposition  was,  of 
course,  out  of  the  question,  but  it  was  hoped  that  an 
abdominal  corset  applied  before  the  patient  got  out  of  bed 
would  give  much  relief.  This  and  the  regulation  of  the 
bowels  gave  great  rehef. 

Visceroptosis  in  the  Male  Sex 

Case  44. — Mr.  M.,  aged  42,  had  a  dropped  stomach  which 
did  not  interfere  seriously  with  his  business  and  public 
activities.  On  my  advice  he  wore  an  abdominal  spirella 
corset.  During  the  time  of  the  war,  he  was  over- worked 
and  had  a  gastric  and  general  physical  breakdown  in  1919. 
I  saw  him  with  his  ordinary  medical  attendant.  He  had 
been  kept  in  bed  for  three  weeks  and  was  fed  on  fluid  nourish- 
ment. He  had  lost  weight  and  felt  weak  and  unfit  for  work 
before  being  confined  to  bed.  He  was  very  lean,  but  his 
colour  was  good.  The  position  of  the  stomach  was  visible. 
The  lesser  curve  was  below  the  level  of  the  umbilicus,  while 
the  greater  curve  was  still  lower.  Peristalsis  was  evidenced 
by  the  varying  degrees  of  prominence  of  the  area  referred 
to.  Epigastric  and  abdominal  reflexes  were  active,  and  the 
peristalsis  of  the  stomach  could  be  stimulated  by  flicking 
the  abdomen.  Succussion  was  readily  produced  by  the 
hand  placed  over  the  organ.  He  was  brought  to  a  nursing 
home  and  the  limits  of  the  organ  traced  and  watched. 
He  was  allowed  a  more  liberal  diet  and  the  condition  of  the 
stomach,  soon  after  a  meal  and  two  or  three  hours  later, 
was  watched  for  two  days,  and  it  was  evident  that  emptying 
took  place  satisfactorily.  The  liver  was  depressed  and 
from  this  combination  of  observations  there  was  no  reasonable 
doubt  that  the  condition  was  a  visceroptosis.  There  was 
no  pain,  and  there  had  at  no  time  been  pain  such  as  occurs 


i82  THE   INTESTINAL  TRACT 

in  ulcer.  Congenital  stenosis  of  the  pylorus  was  excluded 
by  the  absence  of  retention  of  food  and  by  the  shape  and 
size  of  the  organ.  Examination  of  gastric  contents  showed 
abundant  free  HCl.  To  check  the  foregoing  observations 
he  was  X-rayed  by  Dr.  Hope  Fowler. 

In  the  upright  position  the  picture  was  a  very  striking 
and  unusual  one  :  the  bismuth  meal  filled  and  was  grasped  by 
the  proximal  two  thirds  of  the  viscus,  while  the  distal  third 
showed  a  narrow  track  of  bismuth  succeeded  by  an  air- 
containing  area,  the  air  having  been  carried  down  to  the 
pylorus  by  the  weight  of  the  bismuth  meal.  In  the  recum- 
bent position,  Fig.  27  shows  the  alteration  in  the  position 
of  the  stomach  consequent  on  the  change  of  posture  ;  while 
the  air  had  risen  to  the  fundus  and  the  bismuth  occupied 
the  whole  of  the  rest  of  the  organ.  This  figure  corresponded 
sufficiently  closely  to  the  tracing  taken  in  the  nursing  home 
with  the  patient  in  bed.  The  X-ray  examination  confirmed 
the  presence  of  active  peristalsis.  Examined  after  a  lapse 
of  three  hours,  it  was  seen  that  the  large  bismuth  meal  had 
passed  the  pylorus  with  the  exception  of  a  small  quantity. 
Fig.  28,  taken  the  following  morning  after  the  bowels  had 
moved,  showed  that  both  the  hepatic  flexure  and  the  splenic 
flexure  were  below  the  level  of  the  crest  of  the  ilium,  and 
thus  fully  confirmed  the  opinion  that  we  were  dealing  with 
an  enteroptosis  in  a  patient  with  visceroptosis. 

Remarks. — ^This  case  illustrates  very  clearly  the  condi- 
tion which  has  been  described,  and  shows  how  entirely 
unsuitable  such  a  case  is  for  gastro-enterostomy.  The 
question  whether  surgery  is  ever  likely  to  be  able  to  success- 
fully deal  with  such  a  condition  has,  I  venture  to  think,  to 
be  answered  in  the  negative.  A  visceroptosis  like  this  must 
be  regarded  as  congenital,  or  as  coming  on  early  in  life 
from  a  congenital  defect  in  the  maintaining  power  of  attach- 
ments. Notwithstanding  the  lowering  of  the  normal 
anatomical  position  of  the  viscera,  the  stomach  had  ample 
power  in  its  musculature,  the  pyloric  outlet  was  not  narrowed, 
nor  was  it  so  placed  as  to  present  a  difficulty  to  the  propulsion 
of  food  from  stomach  to  duodenum.     There  was  no  serious 


O 


U5 


O 


S3 
J     O    c« 


[To  /act;  ^age  iSz. 


PTOSIS  OF  TRANSVERSE  COLON  1S3 

difficulty  to  the  passage  of  intestinal  contents  along  the 
colon,  past  the  acute  hepatic  and  splenic  flexures,  for  not 
only  did  the  bismuth  pass  in  reasonable  time,  but  the  patient 
did  not  suffer  appreciably  from  constipation.  He  suffered 
from  a  measure  of  flatulence  but  not  to  a  greater  degree 
than  many  persons  whose  viscera  are  normal  in  position. 
An  abdominal  corset  properly  adjusted  proved  of  great 
value  to  the  patient  and  enabled  him  to  lead  a  strenuous 
professional  life. 

Ptosis  of  Transverse  Colon  :  Air-block 

Case  45. — Miss  C,  aged  45,  consulted  me  as  she  was 
vomiting  daily,  had  a  feehng  of  great  fullness  after  food, 
referred  both  to  the  stomach  and  to  behind  the  upper  part 
of  the  sternum,  and  of  very  obstinate  constipation.  She 
thought  that  a  gastro-enterostomy  had  been  performed  for 
a  gastric  ulcer  fifteen  months  before.  The  vomiting  and 
the  constipation  had  been  worse  since  the  operation,  and 
she  was  unfit  for  work  of  any  kind. 

Examination  of  the  abdomen  showed  the  stomach  to 
be  in  practically  the  same  position  as  in  the  previous  patient. 
The  vomit  consisted  of  softened  and  partially  digested 
food  with  much  mucous.  On  chemical  examination  it 
showed  no  free  acid  on  three  occasions.  Bringing  up 
wind  or  vomiting,  which  was  always  accompanied  by  much 
coming  up  of  wind,  gave  great  rehef.  With  a  history  such 
as  was  given  the  presumption  was  that  the  gastro- 
enterostomy opening  was  not  functioning,  but  to  test  this 
it  was,  of  course,  necessary  to  have  recourse  to  X-ray  exami- 
nation. This  showed  the  stomach  to  be  in  much  the  same 
position  as  in  the  previous  case,  but  there  was  no  trace  of  a 
gastro-enterostomy  opening.  I  communicated  with  the 
surgeon  who  had  operated  on  her,  when  it  was  ascertained 
that  a  gastro-enterostomy  had  not  been  done,  but  that  a 
gastric  ulcer  had  been  excised  and  the  appendix  removed. 
The  X-ray  examination  confirmed  the  position  of  the 
stomach    and    showed    air-swallowing.     Air-swallowing,   as 


i84  INTESTINAL  TRACT 

has  been  already  pointed  out,  is  prone  to  occur  in  hypo- 
chlorhydria.  The  operative  measures  had  not  been  effective 
in  removing  the  patient's  symptoms ;  in  fact,  she  was 
insistent  in  asserting  that  they  had  made  her  worse.  On 
following  the  bismuth  in  this  case,  as  seen  in  Fig.  29,  taken 
nineteen  and  a  half  hours  after  it  was  given,  the  transverse 
colon  at  its  most  dependent  part  was  very  low,  a  condition 
which  in  some  quarters  is  looked  upon  as  pathological  and 
even  called  enteroptosis.  In  this  patient,  in  spite  of  this 
low  position  of  the  transverse  colon,  the  hepatic  and  splenic 
flexures  were  not  nearly  as  low  as  in  the  other  cases  we  have 
given.  The  position  of  the  bismuth  in  the  caecal  region 
might  mislead  were  it  not  shown,  as  is  shown  at  B  on  the 
figure,  that  there  was  a  great  block  of  air  in  the  hepatic 
flexure  and  in  the  colon  on  either  side  of  it.  This  air  space 
evidently  acted  as  a  serious  barrier  to  the  passage  of  the 
bismuth,  for  at  the  end  of  forty-eight  hours  little  more 
bismuth  had  passed  it,  as  shown  in  Fig.  30.  She  was  treated 
as  a  case  of  hypochlorhydria  with  air-swallowing,  and  a 
suitable  laxative  was  given. 

Ptosis  of  Hepatic  Flexure  only 

Case  46. — Mr.  S.  was  suffering  from  pain  in  the  upper 
half  of  the  abdomen  and  constipation  which  was  difficult 
to  overcome  and  was  not  getting  less  troublesome.  On 
examination  there  was  a  doughy  mass  to  be  felt  in  the  right 
hypochondrium  which  was  neither  liver  nor  a  displaced 
kidney  and  was  therefore  the  hepatic  flexure  of  the  colon 
full  of  faeces.  It  was  tender  on  palpation.  Faeces  could  be 
felt  in  the  transverse  colon  about  an  inch  above  the  umbiHcus. 
X-ray  examination  in  the  upright  position  showed  marked 
ptosis  of  the  hepatic  flexure,  as  seen  in  Fig.  31,  taken  twenty- 
four  hours  after  the  bismuth  was  given.  It  will  be  noted 
that  there  are  two  bends  on  the  colon  here  instead  of  one, 
but  that  the  bismuth  nevertheless  was  being  propelled  forward, 
although  slowly.  At  the  end  of  forty-eight  hours  I  examined 
the  abdomen  with  the  patient  on  the  X-ray  couch  and  had 


QQ 


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[To  /ace  page  184. 


{To  face  page  185. 


COMPLICATIONS   OF   ENTEROPTOSIS         185 

no  difficulty  in  defining  l^y  palpation  the  position  of  the 
hepatic  flexure  and  of  the  transverse  colon.  The  screen 
showed  these  observations  to  be  absolutely  correct.  The 
position  with  the  patient  recumbent  is  shown  in  Fig.  32. 
That  the  double  bend  of  the  colon  was  seriously  interfering 
with  the  passage  of  the  bismuth  was  evident.  To  deal 
surgically  with  the  condition  was  out  of  the  question,  for 
the  time  at  least.  After  some  trouble  we  arrived  at  a 
laxative  which  promised  to  keep  the  flexure  more  or  less 
empty. 

Complications  of  ENTERonosis 

While  enteroptosis  is  not  suitable  for  operative  interposi- 
tion,  conditions  may  emerge  which  require  special  treat- 
ment. These  are  in  my  experience  :  (i)  Hyperchlorhydria, 
(2)  hypochlorhydria,  (3)  appendicitis,  (4)  gastric  or  duodenal 
ulcer. 

Constipation  is  such  a  common  accompaniment  that  its 
correction  becomes  almost  a  matter  of  routine  It  can 
be  counteracted  if  sufficient  care  is  taken  to  find  the  most 
suitable  laxative  and  the  best  time  to  give  it. 


CHAPTER   XVII 

APPENDICITIS 

The  consideration  of  this  common  malady  is  begun  by 
reproducing  the  paper  on  its  diagnosis  and  indications  for 
treatment  prepared  for  opening  a  discussion  on  the  subject 
at  the  Edinburgh  Medico-Chirurgical  Society  some  years 
ago.  The  reason  for  reproducing  it  here  is  that  the  state- 
ments and  argument  submitted  at  that  time  are  apphcable 
to-day.  Increased  experience  has  given  greater  confidence, 
and  has  put  the  questions  surrounding  the  appendix  in  more 
accurate  and  fixed  perspective,  as  will  be  shown  at  the  end 
of  the  chapter. 

Pathology,  Diagnosis,  and  Indications  for 

Treatment  - 

Nothing  is  more  valuable  and  nothing  can  be  more  mis- 
leading in  medicine  than  personal  or  individual  experience. 
This  seeming  paradox  is  perhaps  specially  applicable  to  the 
clinical  and  therapeutic  questions  which  surround  the 
caecum,  for  in  this  domain  each  individual  physician,  surgeon, 
and  general  practitioner  tends  to  base  his  views  and  methods 
on  his  personal  experience.  One  man  calls  in  the  knife  the 
moment  he  scents  appendicitis  ;  another  holds  lingeringly 
to  the  dying  faith  in  a  stercoral  typhlitis  and  perityphlitis, 
and  each  man  is  prone  to  continue  to  act  in  accordance  with 
the  results  of  a  limited  personal  experience.  It  is  now 
more  than  twenty  years  since  the  vermiform  appendix 
gained  recognition  as  the  main  factor  in  what  aforetime 

^  The  opening  paper  read  at  the  discussion  on  this  subject  before  the 
Edinburgh  Medico-Chirurgical  Society  on  Jan.  30th,  1904, 

186 


PATHOLOGY    AND   DIAGNOSIS  187 

was  attributed  to  other  causes.  The  predominance  of  the 
appendix  in  this  relationship  has  been  steadily  asserted 
and  hundreds  of  operations  have  afforded  opportunities 
for  the  confirming  of  its  position  and  for  a  reasonable 
classification  of  the  morbid  changes  which  affect  it.  In 
this  connection  it  will  not  be  uninteresting  to  know 
that  in  the  medical  statistics  of  the  Edinburgh  Royal 
Infirmary  for  1891-92  there  are  four  cases  of  appendicitis, 
three  of  t3^phlitis,  and  nine  of  perityphlitis.  In  1894-95 
the  cases  of  appendicitis  rose  to  twenty-one,  while  peri- 
typhlitis has  two,  and  typhlitis  has  disappeared  from  the  list. 
In  1901-02  both  terms  have  disappeared  and  appendicitis 
only  is  retained.  Many  writers  have  formally  given  the  old 
typhlitis  and  perityphUtis  a  place  in  the  classical  mythology 
of  medicine  and  assure  us  that  no  one  has  ever  seen  or  ever 
will  see  a  simple  perforation  of  the  Ccecal  wall  or  a  peri- 
t3^phlitis  not  due  primarily  to  the  appendix.  Some  writers 
are  more  judicious  and  recognise  a  small  percentage  of  such 
cases,  some  even  placing  them  as  high  as  five  per  cent. 
Were  the  statements  of  the  former  case  to  be  taken  as 
correct  I  could  claim  a  unique  experience,  for  in  a  com- 
paratively small  experience  I  have  had  four  such  cases.  1 
have  had  three  cases  of  acute  perityphlitis  due  to  primary 
lesion  at  the  cacum  ;  one  case  at  the  operation  showed 
marked  pericaecal  inflammation,  while  the  appendix  showed 
none,  and  a  few  daj^s  later  we  had,  unfortunately,  the  oppor- 
tunity of  seeing  faecal  ulcers  in  the  caecum  ;  another  fatal 
case  was  the  result  of  perforation  of  one  of  a  number  of 
faecal  ulcers  ;  the  third  occurred  in  an  old  man  and  proved 
rapidly  fatal  without  perforation  or  ulcer  ;  the  fourth  case, 
also  a  fatal  one,  was  of  chronic  peritjrphlitic  burrowing 
abscess  in  which  the  appendix  was  not  involved  and  where 
the  diagnosis  before  I  saw  the  patient  was  maHgnant  disease. 
I  mention  m}^  experience  to  accentuate  one  half  of  the  seem- 
ing paradox  with  which  I  opened — namely,  that  nothing  may 
be  more  misleading  than  the  personal  experience  of  any  one 
of  us  if  taken  by  itself  and  not  brought  into  relations  with 
the  experience  of  others.     Whatever  hngering  sentiment  may 


i88  THE   INTESTINAL  TRACT 

cling  to  the  older  views,  the  evidence  is  overwhelming  that 
in  something  between  95  and  100  per  cent,  of  acute  affections 
at  the  caecum  the  primary  seat  of  grave  trouble  is  the 
appendix,  and  that  were  it  not  for  the  appendix  perityphHtis 
would  be  a  rare  occurrence. 


The  Diagnosis  of  Acute  Appendicitis 

In  approaching  this  question  it  is  necessary  to  have  a 
clear  conception  of  the  condition  we  seek  to  diagnose.  I  do 
not,  however,  propose  to  dwell  in  detail  upon  the  varied 
anatomical  changes  which  are  met  with  in  the  appendix  as 
a  result  of  morbid  action  ;  but  there  are  some  points  which 
materially  assist  us  in  our  efforts  at  differential  diagnosis. 
It  is  important  to  bear  in  mind  in  the  first  place  that  the 
appendix  varies  in  length  and  in  calibre,  in  its  position 
relative  to  the  caecum,  and  in  the  form  of  its  mesentery. 
Moreover,  the  meso -appendix  also  carries  its  blood-supply. 
In  the  second  place  two  morbid  conditions  may  arise  in 
connection  with  the  appendix — namely,  (i)  inflammation 
and  (2)  necrosis,  going  on  to  gangrene.  The  intensity  of 
the  inflammation  varies  from  a  catarrh  of  its  mucous  mem- 
brane to  a  parietal  inflammation  involving  all  its  coats  or 
an  inflammation  accompanied  by  ulcers  which  may  or  may 
not  perforate.  Necrosis  or  gangrene  of  the  entire  appendix 
is  sometimes,  if  not  always,  determined  by  a  short  mesentery 
which  gives  the  appendix  a  sickle  shape  or  by  some  other 
mechanism  which  interferes  with  the  blood-supply.  Van 
Cott  goes  so  far  as  to  hold  that  the  primary  local  condition 
in  appendicitis  is  a  trophic  one  which  makes  it  a  point  of 
least  resistance  for  the  action  of  virulent  organisms.  The 
fact  that  appendicitis  is  much  less  frequent  in  women  than 
in  men  is  probably  in  part  due  to  there  being  a  second  source 
of  blood-supply  in  women  by  way  of  the  appendiculo-ovarian 
ligament.  This  anatomical  point  is  of  important  significance, 
for  various  conditions  at  the  caecum  or  of  the  appendix 
itself  may  impede  and  even  arrest  the  arterial  blood-supply 
so  that  necrosis  and  gangrene  readily  follow.      The  two 


DIAGNOSIS    OF  ACUTE   APPENDICITIS  189 

other  anatomical  points  which  seem  to  me  of  most  importance 
are  the  caUbre  and  perhaps  the  length  of  the  appendix  or 
the  relation  between  these  and  the  relation  of  the  lumen  of 
the  appendix  to  the  cavity  of  the  csecum.  I  do  not  venture 
to  lay  down  definite  rules,  but  it  is  by  recognizing  the  exist- 
ence of  differences  in  the  directions  indicated  that  we  are 
able  to  understand  how  the  appendix  in  certain  persons, 
from  its  shape,  size,  position,  or  curvature,  is  bound  to  give 
trouble  to  its  possessor  on  the  slightest  provocation,  while 
in  others  from  birth  to  death  it  never  indicates  its  existence, 
no  matter  what  the  gastro-intestinal  experience  of  the 
individual  may  have  been  in  other  respects. 

On  this  anatomical  difference  of  position  and  of  lumen 
depends  and  hangs  the  question  of  inflammation.     Why  does 
the  appendix  inflame  and  not  the  caecum  ?     I  take  from 
A.  O.  J.  Kelly  of  Philadelphia  the  idea,  which  I  apply  more 
generally,  that  the  question  is  essentially  one  of  drainage. 
Secretion  from  the  mucous  membrane  of  the  appendix  or 
faecal  matter  entering  from  the  caecum  and  not  expelled  form 
an  excellent  nidus  for  the  growth  of  the  micro-organisms 
of  the  intestine,  but  such  conditions  do  more — they  have 
been    shown    experimentally    to    be    the    very    conditions 
which  rapidly  exalt  the  virulence  of  that  otherwise  harm- 
less organism,  the  bacillus  coH  communis.     Kelly,  Deaver, 
and  others  have  shown  by  a  large  number  of  observations 
that  this  organism  is  the  most  common  bacterial  agent, 
although  not  the  only  one,  in  the  determination  of  acute 
inflammation  in  the  appendix.     It  is  important  to  realize 
that  the  exaltation  of  virulence  of  the  organism  mentioned 
takes  place  in  other  bowel  conditions  as  obstruction,  strangu- 
lation, and  volvulus,  but  for  our  present  purpose  it  is  still 
more  important  to  know  that  it  also  takes  place  in  diarrhoeic 
conditions   and   in    constipation.     The    variability   in    the 
measure  of  this  exaltation  of  virulence  determines  the  great 
differences  in  the  clinical  manifestations  and  in  the  ultimate 
issue  in  individual  cases.     But  this  question  of  drainage 
requires   further   consideration,  and   in   this   connection    1 
beheve  that  the  condition  of  the  mucous  membrane  of  the 


190  THE   INTESTINAL  TRACT 

caecum  as  a  factor  in  causing  the  block  is  forgotten.  We 
never  forget  that  a  duodenal  catarrh  causes  a  block  of  the 
common  bile  duct,  but  at  the  caecum  we  are  so  taken  up 
with  the  appendix  that  we  ignore  the  possibiUty  of  the 
block  which  determines  and  keeps  up  the  inflammation 
being  caused  by  a  like  condition  at  its  mouth.  We  must, 
I  think,  accept  this  proposition.  The  block,  however,  may 
be  associated  with  a  faecal  concretion  in  the  appendix  and 
this  association  is  frequently  present  in  the  fulminating  type 
of  appendicitis.  Here  also  we  have  to  be  on  guard  against 
unwarrantable  conclusions.  Faecal  concretions  are  common 
in  the  appendix  without  any  trace  of  irritation,  but  if  a 
faecal  concretion  and  a  catarrh  operate  together  then  we 
have  the  conditions  which  may  lead  to  rapid  perforation. 
But  even  then  the  issue  turns  on  the  virulence  of  the  organism 
present.  I  have  seen  a  faecal  mass  on  a  surgeon's  finger  tip 
a  second  or  two  after  he  had  introduced  his  hand  into  the 
abdominal  cavity  and  yet  the  patient  never  showed  an 
anxious  symptom  after  the  removal  of  the  perforated 
appendix.  In  connection  with  this  question  of  faecal  con- 
cretion Fowler  records  a  unique  case  in  which  gangrene  of 
the  appendix  was  due  to  a  gall-stone  entrapped  and  stuck 
at  its  orifice. 

Following  upon  the  foregoing  considerations  the  first 
point  which  appears  to  me  to  call  for  consideration  is  the 
question  of  "  appendicular  colic  " — is  there  such  a  condition, 
and  v/hat  view  do  we  take  of  it  ?  The  sudden  onset  of  severe 
abdominal  pain,  perhaps  vomiting,  muscular  rigidity  of  the 
abdominal  wall  or  of  the  lower  right  segment  of  it,  and 
tenderness  are  known  to  all  of  us.  Talamon  argues  that 
this  sudden  onset  of  pain  is  due  to  a  scybalous  concretion 
formed  in  the  caecum  becoming  suddenly  engaged  at  the 
mouth  of  the  appendix.  Fowler  denies  the  occurrence  of 
appendicular  cohc  ;  Hawkins  questions  it.  Personally  I  do 
not  see  how  the  manifestations  referred  to  are  to  be  other- 
wise explained  than  by  a  temporary  embarrassment  to  the 
appendix  drainage.  We  all  know  that  an  attack  of  the 
kind  indicated  may  come  on  in  the  night ;    that  after  hot 


DIAGNOSIS   OF   ACUTE   APPENDICITIS  191 

applications  and  a  dose  of  castor  oil  or  of  a  saline  laxative, 
the  individual  may  be  well  enough  to  be  at  business  that 
day  or  the  following  day.  No  medical  man  sees  him,  for 
the  condition  is  looked  upon  as  indigestion  or  colic  due  to 
constipation  and  only  requiring  domestic  skill.  We  have 
seen  cases  where  a  second  and  a  third  recurrence  of  this 
experience  formed  the  historical  background  to  a  tragedy  ; 
we  have  known  it  repeated  over  a  period  of  many  years  and 
no  tragedy  to  follow. 

This  question  of  appendicular  colic  lies  at  the  threshold 
of  the  diagnosis  of  appendicitis  ;  from  it  you  easily  build 
up  the  whole  chnical  story  of  acute  appendicitis.  You  pass 
from  the  mere  mechanical  and  physical  embarrassment  of 
cohc  to  the  superadded  inflammation,  perforation,  or  necrosis. 
The  symptoms  of  acute  appendicitis  are  common  to  various 
abdominal  illnesses — sudden  onset  of  pain  which  may  be  of 
extreme  severity,  vomiting,  tenderness,  rigidity,  a  measure 
of  shock  with  an  accelerated  and  feeble  pulse,  and  a  varying 
degree  of  elevation  of  temperature — so  that  appendicitis  has 
been  mistaken  for  many  things  ;  amongst  them  are  acute 
indigestion,  gastric  perforation,  internal  hernia,  renal  and 
hepatic  colic,  while  diaphragmatic  pleurisy  and  croupous 
pneumonia  have  been  thought  to  be  appendicitis.  It  would 
be  treating  my  readers  with  scant  respect  were  I  to 
occupy  their  time  with  a  reproduction  of  the  points  deter- 
mining the  differential  diagnosis  in  all  these.  There  are, 
however,  two  phenomena  which  I  venture  to  deal  with — 
namely,  pain  and  tenderness.  With  regard  to  pain  I  am 
often  impressed  by  the  undue  significance  attached  to  the 
site  of  pain  in  abdominal  conditions.  In  acute  appendicitis 
the  pain  is  often  referred  to  the  umbiUcal,  epigastric,  or 
other  region,  or  it  may  be  diffused  all  over  the  abdomen. 
When  pain  is  thus  referred  to  regions  at  a  distance  from 
the  seat  of  lesion  it  frequently  misleads.  When  such 
referred  pains  are  associated  with  surface  tenderness  in  the 
same  regions  they  still  more  commonly  lead  to  an  error  in 
diagnosis.  This  surface  tenderness  or  skin  hypercesthesia 
is   a   great   stumbling-block   in   abdominal   diagnosis,    and 


192  THE  INTESTINAL   TRACT 

accuracy  of  diagnosis  need  never  be  expected  until  we 
have,  by  careful  and  patient  examination,  learnt  to  dis- 
tinguish between  it  and  the  true  tenderness  of  the  diseased 
organ.  We  need  not  discuss  the  paths  of  referred  pains,  but 
it  is  well  to  remember  that  the  nerves  involved  often  carry 
with  them  to  their  terminal  distribution  a  surface  hyper- 
sesthesia.  One  point  where  the  surface  tenderness  is 
common  has  been  engraved  with  the  name  of  McBurney 
and  proves  a  trap  to  the  unwary  clinician.  Surface  tender- 
ness must  not  be  confused  with  deep  tenderness.  At  the 
outset  of  an  attack  the  rigidity  of  the  muscles  may  be  a 
barrier  to  deep  palpation,  but  with  sufficient  patience  it 
is  usually  possible  to  make  out  the  presence  or  absence  of 
deep  tenderness,  and  if  we  are  at  all  successful  in  our  mani- 
pulations pain  can  always  be  elicited  by  pressure  on  an 
inflamed  appendix.  To  indicate  to  you  that  this  mode  of 
examination  may  be  quite  trustworthy,  I  may  mention  that 
in  one  case  I  ventured  to  tell  the  surgeon  into  whose  hands 
I  gave  the  patient  that  the  appendix  was  lying  behind  the 
caecum  and  the  operation  showed  this  to  be  correct ;  in 
other  cases  the  point  of  marked  tenderness  is  only  to  be  found 
by  rectal  examination.  I  saw  with  one  of  my  brethren 
some  time  ago  a  case  in  which  tenderness  was  only  elicited 
in  this  way,  and  it  was  the  only  guide  to  the  origin  of  the 
lesion  causing  symptoms  the  extreme  gravity  of  which  it 
was  easy  to  estimate.  The  situation  of  the  tenderness 
in  such  cases  is,  of  course,  due  to  the  position  of  the 
appendix. 

The  importance  of  being  able  to  elicit  this  direct  tenderness 
of  the  affected  part  cannot  be  exaggerated  ;  it  is  the  key  to 
abdominal  diagnosis  ;  it  is  recognized  by  all  the  authorities — 
Hawkins,  Fowler,  and  Deaver  lay  stress  upon  it.  Deaver 
says  it  is  "  always  present."  Fowler  says  "  in  the  early 
stage  of  the  disease  tenderness  is  only  elicited  when  pressure 
is  made  in  the  immediate  neighbourhood  of  the  appendix 
itself."  Fowler  goes  so  far  when  considering  diagnosis  as 
to  say  that  "  every  case  of  colicky  pains  in  the  abdomen 
suddenly  developed  ^^ith  right-sided  tenderness  should  be 


INDICATIONS   FOR   OPERATION  193 

regarded  as  a  case  of  appendicitis  until  this  supposition  is 
disproved."  Legueu  denies  difficulty  in  diagnosis  save  in 
exceptional  cases.  Nothnagel  refers  one  of  the  difficulties, 
as  I  have  done,  to  a  false  localization  of  the  pain  or  an  unusual 
position  of  the  appendix.  Talamon  holds  that  the  diagnosis 
of  acute  appendicitis  is  as  easy  as  the  diagnosis  of  pneumonia. 
One  warning  I  would  add  with  regard  to  the  state  of  the 
bowels,  and  that  is  that  while  constipation  is  the  rule  it  is 
not  the  invariable  condition.  Some  time  ago  I  was  looking 
after  a  boy  with  diarrhoea,  elevated  temperature,  some 
tenderness  in  the  right  iliac  region,  and  a  history  that  sug- 
gested tuberculous  ulceration  of  the  intestine.  He  was 
seen  for  me  by  another  physician,  but  it  was  left  to  me  to 
realize  a  couple  of  days  later  that  we  had  both  overlooked 
an  appendicitis.  The  patient  fortunately  recovered  after 
operation.  In  fact,  the  diagnosis  of  acute  appendicitis  hangs 
upon  and  depends  upon  our  skill  in  eliciting  the  essential 
and  distinguishing  it  from  the  non-essential  and  incidental. 

Indications  for  Operation 

At  the  outset  of  this  part  of  the  subject  we  have  to  face 
two  strong  currents  of  opinion  which  cannot  be  called  the 
medical  and  the  surgical,  for  the  surgeons  are  found  in  both 
camps.  Indeed,  the  French  surgeon,  Legueu,  divides  even 
his  surgical  confreres  into  radicals  and  opportunists  or  tem- 
porizers. Probably  the  best  designation  for  the  two  schools 
is  to  be  found  in  our  own  Uterature  and  we  may  accept 
the  terms  ' '  radical ' '  and  ' '  conservative  ' '  as  indicating  the 
point  of  distinction  between  them  from  the  operative  stand- 
point. The  radical  school  has  attained  its  full  effulgence 
in  America.  Since  the  publication  of  Fitz's  papers  in  1886 
and  1888  and  the  estabhshment  of  the  appendix  as  the 
dominant  structure  in  the  pathology  of  the  right  iliac  fossa, 
American  surgeons  have  more  and  more  adopted  the  practice 
of  routine  excision  as  soon  as  appendicitis  is  recognized. 
Fitz,  Senn,  Sands,  McBurney,  Price,  Morris,  and  Deaver  are 
all  names  associated  with  this  school.    Legueu  says  :  "  Toute 

13 


194  THE  INTESTINAL  TRACT 

appendicite  doit  etre  operee  a  temps."  If  this  aphorism  be 
adopted  the  position  is  simple ;  differential  diagnosis 
becomes  a  mere  unpractical  refinement  and  there  is  nothing 
left  to  discuss.  The  argument  in  support  of  this  position 
is  that  the  danger  of  perforation  is  great  and  that  it  is 
impossible  to  determine  which  cases  will  perforate  and 
which  mU  not.  This  is  the  main  point :  there  are  also 
minor  although  important  points  to  which  I  need  not 
refer.  This  is  the  point  which  appeals  to  those  of  us  who 
have  learnt  to  dread  the  possibiUty  of  an  intense  toxaemia 
from  peritoneal  infection  and  who  know  how  rapidly  this 
supervenes  in  some  cases.  I  myself  am  so  ahve  to  this  truly 
terrible  aspect  of  acute  appendicitis,  and  the  cases  which  I 
see  are  so  often  cases  in  which  operation  is  clearly  indicated, 
that  were  I  to  take  my  personal  experience  of  the  last  ten 
years  as  my  sole  guide  I  should  not  be  far  from  the  radical 
position.  But  here  again  our  individual  experience  has  to 
be  checked  by  the  knowledge  of  the  results  of  a  wider 
experience. 

The  conservative  school  is  represented  in  this  country  by 
Treves,  Tubby,  and  Hawkins  ;  in  France  by  Talamon  ;  and 
in  Germany  by  Nothnagel.  Hawkins,  on  whose  work  Treves 
leans,  says  of  the  American  school  that  "  the  gravity  of 
disease  of  the  appendix  was  measured  by  the  rapidity 
of  death  in  a  few  fatal  cases  rather  than  by  the  actual 
frequency  with  which  a  fatal  event  occurs."  Referring 
to  some  more  recent  contributions  to  the  subject  he  says  : 
"  They  seem  to  be  compiled  by  a  surgeon  for  the  use  of  a 
physician  concerning  a  disease  which  is  in  all  its  aspects 
familiar  to  the  physician,  but  of  which  the  surgeon  has  seen 
only  the  more  severe  form.  They  assume  a  rate  of  mortality 
from  disease  of  the  appendix  which  has  no  foundation  in 
actual  figures."  Talamon  says  that  the  position  of  the 
partisans  of  the  extreme  view  would  necessitate  operation 
for  every  attack  of  intestinal  colic  attended  with  intense 
pain  locahzed  in  the  right  iliac  fossa,  a  rule  he  thinks 
sufiiciently  absurd  in  itself  and  not  likely  to  be  adopted. 
Nothnagel  speaks  of  the  operation  fanatics.     Treves  says  : 


INDICATIONS   FOR    OPERATION  195 

"  It  would  be  as  wise  to  advise  immediate  operation  in  all 
cases  of  ulcer  of  the  stomach  as  soon  as  a  diagnosis  is  made 
because  some  cases  of  ulcer  of  the  stomach  end  in  a  fatal 
perforation."  Tubby  says  :  "I  am  strongly  inclined  to 
think  that  no  judicious  surgeon  is  prepared  to  tie  himself 
down  to  the  practice  of  routine  early  operation  in  all  cases, 
but  would  prefer  to  watch  his  cases  closely  and  when  in 
doubt  operate  at  once."  The  warrant  for  the  conservative 
position  is  to  be  found  in  the  results  of  a  wider  experience 
rather  than  in  that  embraced  by  the  individual  observer. 
Some  of  these  results  are  as  follows.  Furbringer  in  120 
cases  had  10  per  cent,  of  deaths.  Renvers  had  from  91  to 
92  per  cent,  of  recoveries.  Guttmann  at  the  Moabit  Hospital 
had  96  per  cent,  of  recoveries.  Curschmann  in  453  cases  had 
4 '5  per  cent,  of  deaths  and  9  cases  sent  to  the  surgeons. 
Sahh,  as  the  outcome  of  a  collective  inquiry,  had  a  return  of 
7213  cases  which  showed  that  in  6740  cases  not  operated  on 
8-8  per  cent,  died  and  91 '2  per  cent,  recovered.  Nothnagel 
in  130  cases  had  115  cured  or  improved,  four  deaths  without 
operation,  and  11  cases  sent  to  the  surgeons.  Hawkins's 
statistics  of  the  cases  at  St.  Thomas's  Hospital,  if  we  exclude 
cases  of  perityphlitic  abscess  and  of  general  peritonitis,  show 
190  cases  with  190  recoveries  and  only  one  operated  on.  I 
have  collected  from  the  statistics  of  the  medical  side  of  the 
Edinburgh  Royal  Infirmar}^  from  1891-92  to  1901-02  (that 
is,  ten  years,  for  one  year  is  wanting)  268  cases,  of  which 
189  were  cured  or  relieved,  7  were  unrelieved,  23  died,  and 
49  were  sent  to  the  surgeons.  I  regret  that  the  only  point 
I  could  be  sure  of  in  the  statistics  of  the  surgical  side  was 
that  all  the  cases  of  appendicitis  were  not  operated  on, 
showing  that  the  conservative  school  is  represented  there 
also. 

It  thus  appears  that  in  acute  appendicitis  recovery  takes 
place  in  from  90  to  95  per  cent,  of  cases  ^\ithout  operation. 
This  is  the  position  of  appendicitis  when  it  is  judged  of  by 
a  wide  experience,  and  it  seems  to  me  to  be  in  accord  with 
the  experience  of  many  of  our  brethren  in  general  practice 
in  the  country  and  in  the  provinces  who  have  not  skilled 


196  THE   INTESTINAL   TRACT 

surgical  help  at  their  call  any  and  every  hour  of  the  day  or 
night  as  practitioners  have  in  the  cities.  These  figures  may 
well  prove  a  comfort  to  our  less  favourably  situated  brethren, 
but  they  throw  a  greater  weight  of  responsibility  on  some 
of  us,  for  it  becomes  more  and  more  imperative  to  watch 
with  the  closest  attention  every  individual  case  and  to 
learn  to  determine  the  one  case  in  the  ten  which  if  it  is  to 
be  saved  must  be  submitted  to  the  surgeon's  knife  without 
delay. 

The  first  question  which  ought  to  be  faced  in  every  case 
of  acute  appendicitis  is  :  Is  the  appendix  rapidly  to  perforate 
or  promptly  to  become  gangrenous  ?  Early  perforation  and 
early  gangrene  account  for  most  if  not  for  all  of  the  cases  of 
early  peritonitis  with  grave  toxaemia.  St.  Thomas's  Hospital 
statistics  show  36  in  a  total  of  264  cases  and  of  these  27 
proved  fatal.  Perityphlitic  abscess  may  be  regarded  as  a 
later  development,  but  it  supplies  38  cases  with  28  deaths 
in  the  statistics  of  the  same  hospital.  The  above  question 
ought  to  be  formulated  definitely  in  every  acute  case.  The 
chances  as  shown  by  statistics  are  fully  nine  to  one  against 
perforation ;  but  differential  diagnosis  is  not  based  on 
averages,  and  it  is  equally  poor  comfort  to  be  assured  by 
many  authorities  that  the  question  cannot  be  answered  until 
the  disaster  we  desire  to  anticipate  has  occurred. 

As  I  understand  the  matter  one  great  object  which  the 
promoters  of  this  dicusssion  had  in  view  was  to  elicit  what- 
ever there  is  of  knowledge  and  of  experience  on  this  point 
among  us.  I  myself  approach  it  with  much  diffidence, 
but  there  are  some  points  which  I  venture  to  submit.  The 
first  is  that  if  in  an  acute  attack  I  find  that  there  have  been 
one  or  two  previous  attacks,  even  mild  ones,  I  do  not  hesitate 
to  advise  removal  of  the  appendix  at  once.  My  reason  for 
doing  so  is  that  I  am  satisfied  that  the  anatomical  relations 
of  certain  appendices  are  such  that  appendicular  trouble 
is  bound  to  arise.  Recurrence  is  the  clinical  proof  of  this, 
and  in  any  recurrent  attack  the  appendix  may  perforate 
or  necrose,  so  that  the  sooner  such  appendices  are  removed 
the  better.     The  second  point  is  that  if  an  acute  appendicitis 


INDICATIONS    FOR   OPERATION  197 

has  an  early  rigor  immediate  removal  is  indicated.  I  have 
seen  early  rigor  followed  speedily  by  gangrene.  But  this 
only  disposes  of  a  small  number  of  acute  cases.  When  we 
come  to  the  remaining  cases,  and  if  we  are  not  to  adopt 
routine  removal  in  all  instances,  the  questions  necessarily 
arise  :  What  are  we  to  do  ?  How  long  are  we  to  continue 
the  medical  treatment  we  may  have  adopted  ?  and,  What 
indications  are  to  guide  us  in  determining  for  or  against 
operation  ?  As  regards  the  first  of  these  it  is  quite  clear 
that  something  must  be  done  and  always  is  done.  You  all 
know  that  purgatives  are  anathematized  and  that  if  perfora- 
tion occur  after  the  administration  of  such  the  medical  man 
who  has  ordered  them  is  looked  upon  as  a  most  culpable 
person.  I  have  not  given  purgatives  in  these  cases  for  many 
a  day,  but  in  the  earlier  years  of  practice  I  used  repeated 
doses  of  saline  laxatives  in  what  we  called  perityphlitis  and 
I  had  not  then  a  single  death.  All  of  us  have  seen  cases 
where  the  so-called  "  fatal  "  purgative  has  been  taken  by  the 
patient  on  his  own  initiative  and  his  appendix  has  not 
ruptured.  Such  experiences  have  their  due  place.  I  have 
referred  to  the  point  as  I  venture  to  think  that  statements 
are  made  in  this  connection  which  are  mere  presumptions 
and  are  based  upon  isolated  and  misinterpreted  occurrences. 
The  next  point  that  arises  for  consideration  is  the  relief 
of  pain.  This  is  sought  for  by  either  hot  or  cold  local 
applications  ;  these  are  at  least  harmless.  When,  however, 
we  go  beyond  local  measures  we  at  once  enter  a  region 
where  there  is  a  great  difference  of  opinion.  You  all  know 
how  opium  and  its  chief  alkaloid  are  condemned.  Their 
administration  relieves  pain  and  gives  rest  to  the  patient 
and  to  the  caecum.  The  main  argument  against  their  use 
is  that  they  "  mask  symptoms"  and  so  they  do  to  the  in- 
experienced and  the  unwary.  Nothnagel  is  a  great  advocate 
of  opium,  and  while  I  am  not  prepared  to  follow  his  method 
I  have  found,  as  he  contends,  that  its  previous  administration 
need  not  mislead,  and  I  can  hardly  imagine  the  hospital 
physician  or  surgeon  being  seriously  misled  by  the  mere 
relief  of  pain  consequent  upon  its  administration.     If  given 


1 98  THE   INTESTINAL  TRACT 

at  all  it  ought  certainly  to  be  limited  in  its  use  to  the  allevia- 
tion of  intense  suffering  and  as  a  temporary  expedient.  I 
even  go  so  far  as  to  say  that  the  call  for  the  continued  use 
of  opium  is  an  indication  that  operation  is  desirable.  Per- 
sonally I  prefer  to  use  belladonna,  which  relieves  spasm  and 
does  not  dull  sensory  centres.  There  is  only  one  further 
procedure  which  is  worth  referring  to  and  that  is  lavage. 
There  exists  in  regard  to  its  use  some  degree  at  least  of  the 
same  feeUng  as  exists  about  the  giving  of  laxatives.  The 
reasons  given  against  its  use  are  open  to  question.  That 
lavage  of  the  colon  and  csecum  is  dangerous  and  may  cause 
either  perforation  or  gangrene  is  a  mere  arbitrary  pre- 
sumption and  has  no  foundation  in  fact.  Granting  that  the 
essential  factors  in  the  production  of  acute  appendicitis  are 
as  I  have  represented,  there  is  no  measure  which  one  would 
more  instinctively  turn  to  than  csecal  lavage,  owing  to  the 
effect  it  would  have  upon  the  mucous .  membrane  at  the 
mouth  of  the  appendix  and  the  effect  it  might  have  in  aid- 
ing the  re-establishment  of  appendix  drainage.  Professor 
Bourget  of  Lausanne  has  published  an  important  monograph 
on  this  method  of  treatment.  He  uses  it  in  all  cases  of  acute 
appendicitis  which  come  under  his  care,  and  he  only  advises 
operation  after  the  acute  symptoms  have  subsided  and  in 
selected  cases.  In  his  monograph  he  gives  the  details  of 
twenty-three  cases  which  occurred  in  his  hospital  practice 
between  January,  1901,  and  February,  1902,  which  he 
treated  on  the  lines  indicated  without  a  single  death  ;  and 
the  clinical  records  show  that  some  of  the  cases  were  of  a 
grave  t^^pe.  M3/  own  experience  of  this  method  of  treatment 
is  too  limited  to  sa}^  more  about  it  than  that  so  far  as  I  have 
yet  used  it  I  am  satisfied  with  the  results. 

Having  thus  indicated  the  medical  measures  which  may 
legitimately  be  used  when  brought  face  to  face  wdth  a  case 
of  acute  appendicitis,  the  serious  questions  still  remain  : 
How  long  are  we  to  continue  to  use  whichever  measures  we 
may  have  adopted  ?  How  long  are  we  to  wait  for  alleviation 
of  the  condition  at  the  appendix  ?  and,  What  are  the  indica- 
tions that  surgical  interference  is  the  wise  course  to  adopt  ? 


INDICATIONS   FOR   OPERATION  199 

I  can  endorse  the  precept  laid  down  by  others  that  every 
individual  case  ought  to  be  regarded  with  great  seriousness 
and  is  to  be  closely  watched  for  the  appearance  of  any  un- 
favourable symptom.  There  are,  however,  definite  indica- 
tions which  help  us  to  determine  those  questions,  and  an 
accurate  mental  picture  of  the  steps  of  morbid  processes  in 
the  appendix  materially  aids  us.  Some  of  those  indications 
are  as  follows.  The  continuance  of  severe  pains  in  spite  of 
local  applications  and  the  administration  of  belladonna 
internally  may  be  taken  as  an  indication  for  operation, 
for  it  mirrors  almost  certainly  blockage  and  severe  inflamma- 
tion. The  recurrence  of  paroxysms  of  pain  indicates 
operation,  for  it  is  a  proof  that  the  appendix  drainage  is 
being  recurrently  interrupted  and  the  sooner  such  an 
appendix  is  removed  the  better  for  the  patient.  Great 
importance  is  to  be  attached  to  the  condition  at  the  caecum 
as  revealed  by  careful  and  patient  palpation  ;  locaHzed 
tenderness  and  swelling  are  the  two  phenomena  which 
demand  much  more  patient  handling  than  they  often  get. 
If  the  case  has  been  ushered  in  by  great  pain  and  yet  appears 
to  be  a  mild  one  as  judged  by  cursory  examination,  be  on 
your  guard  ;  that  is  the  kind  of  case  that  can  perforate  within 
forty-eight  hours.  If  pain  subsides  and  the  appendix  remains 
very  tender  notwithstanding  the  use  of  local  applications 
and  the  internal  administration  of  belladonna,  do  not  wait 
many  hours  for  lessening  of  tenderness,  for  the  appendix 
may  be  already  necrosed  and  will  shortly  be  gangrenous  or 
a  concretion  may  be  completing  a  perforation.  In  these 
instances  of  necrosis  and  of  threatening  perforation  the 
leucocyte  count  gives  no  sufficient  warning  of  the  threatening 
disaster.  Hubbard,  Dunham,  Da  Costa,  Wassermann,  and 
Brown  have  all  dealt  with  the  question  of  leucocytosis  in 
appendicitis,  but  on  this  important  point  no  strong  claim  of 
its  value  is  made.  I  am  very  suspicious  of  severe  onset,  no 
great  local  swelHng,  only  moderate  tenderness  over  the  caecum, 
but  a  point  where  deep  palpation  reveals  acute  localized 
tenderness.  If  it  is  reahzed  that  a  blocked  and  inflamed 
appendix  accounts  for  such  phenomena  you  will  want  proof 


200  THE   INTESTINAL  TRACT 

within  twenty -four  hours  that  that  appendix  has  clearly 
lessened  in  tenderness,  and  if  it  has  not  you  will  want  to  have 
it  removed.  I  again  lay  great  stress  upon  the  cultivation 
of  abdominal  palpation  as  a  means  of  great  value,  not  only 
in  diagnosing  appendicitis  but  in  estimating  the  progress  of 
an  acute  attack.  In  the  less  rapid,  which  is  also  the  more 
common,  type  of  case,  with  marked  swelling  and  tenderness 
over  the  whole  caecum,  the  temperature  and  the  pulse  are 
an  index  of  the  measure  of  inflammatory  reaction  and  the 
blood  examination  shows  a  leucocytosis  of  somewhere  about 
15,000  as  a  rule.  If  the  local  and  general  symptoms  do  not 
speedily  subside  under  such  measures  as  have  been  indicated, 
and  if  on  further  blood  examination  it  is  found  that  the 
leucocytosis  reaches  20,000  or  more,  the  case  falls  entirely 
to  the  surgeons,  for  pus  has  almost  certainly  formed  and  the 
condition  has  to  be  treated  on  general  surgical  principles. 

I  have  sought  in  what  I  have  said  to  formulate  points 
which  present  themselves  before  grave  peritoneal  infection 
has  taken  place.  When  it  has  taken  place  the  facies 
abdominalis  and  the  rapid  and  small  pulse  are  indication 
enough  of  what  has  happened.  What  the  promoters  of  this 
discussion  want  to  bring  out  are  the  indications  which  will 
enable  us  to  anticipate  this  danger  and  by  anticipation  to 
avoid  it,  and  to  this  object  my  remarks  have  been  directed. 
When  disaster  has  occurred  there  is  Httle  difficulty  in 
recognizing  it  and  there  are  not  two  opinions  as  to  the  proper 
course  to  adopt.  Beyond  sa3dng  this  I  do  not  further  pursue 
this  side  of  acute  appendicitis. 

Permit  me  in  conclusion  to  reiterate  the  main  points  in 
the  Une  of  thought  which  I  have  endeavoured  to  present  in 
this  paper,  i.  Certain  appendices  are  so  formed  anatomi- 
cally that  they  of  necessity  give  rise  to  trouble.  2.  Inter- 
ference with  the  drainage  of  the  appendix  is  an  important 
factor  in  determining  inflammation.  3.  The  occurrence  of 
appendicular  cohc  may  be  taken  as  a  warning  that  dangerous 
anatomical  conditions  exist  in  connection  with  the  appendix. 
4.  In  all  abdominal  cases  detailed  palpation  should  be  care- 
fully and  patiently  carried   out.     5.  Too  much   emphasis 


INDICATIONS   FOR  OPERATION  201 

must  not  be  put  on  the  site  of  pain  or  on  superficial  tender- 
ness. Palpation  should  be  directed  towards  ascertaining 
the  actual  condition  of  the  diseased  part.  6.  Statistics 
show  that  from  90  to  95  per  cent,  of  cases  recover  without 
operation  and  the  chances  against  recurrence  are  as  three 
to  one  or  thereby.  Therefore  routine  removal  cannot  be 
accepted  as  necessary.  7,  Operate  at  once  in  any  case  with 
a  history  of  previous  attacks,  also  in  all  cases  commencing 
with  a  rigor.  8.  The  chief  difficulty  lies  in  the  early  recog- 
nition of  the  cases  in  which  the  appendix  will  necrose  or 
perforate  rapidly.  In  this  connection  suspect  cases  which 
show  constitutional  disturbance  with  httle  inflammatory 
reaction  round  the  caecum  but  with  marked  tenderness  on 
deep  palpation  and  an  ordinary  degree  of  leucocytosis. 
9.  In  cases  which  do  not  call  for  immediate  operation  pain 
may  be  relieved  by  hot  or  cold  local  applications  and  by  a 
cautious  and  sparing  use  of  opium  or  morphine  or  of  bella- 
donna. Lavage  may  give  good  results.  10.  Medical  treat- 
ment should  not  be  rehed  on  for  more  than  from  twenty- 
four  to  forty-eight  hours  if  severe  pain  continues  or  an  acute 
tenderness  on  deep  palpation  still  remains.  11.  Later  in 
the  disease  a  continuance  of  the  local  and  general  symptoms 
along  with  a  high  leucocyte  count  indicates  the  presence 
of  pus  and  the  necessity  for  operative  interference. 

Bibliography. — Bourget :  Typhliie,  P/rityphlite,  Appendicite.  Brown  : 
International  Clinics,  vol.  iv.,  twelfth  series,  1903.  Da  Costa:  American 
Journal  oj  the  Medical  Sciences,  November,  1901.  Deaver  :  A  Treatise 
on  Appendicitis,  Philadelphia,  1900.  Dunham :  Annals  of  Surgery, 
vol.    xxxi.,    1900.     Fowler :     A    Treatise    on    Appendicitis,    Philadelphia, 

1894.  Hawkins  :     On   Diseases    of    the    Vermiform    Appendix,    London, 

1895.  Hubbard  :  Boston  Medical  and  Surgical  Journal,  vol.  cxlii.,  1900. 
A.  O.  J.  Kelly  :  Transactions  of  the  College  of  Physicians,  Philadelphia, 
1899.  Kelynack :  A  Contribution  to  the  Pathology  of  the  Vermiform 
Appendix,  London,  1893.  Legueu  :  Traitement  de  V Appendicite,  Paris, 
1899.  Nothnagel :  Skolikoiditis  und  Perityphlitis,  Specielle  Pathologie 
und  Therapie,  Band  xvii.,  V^ien,  1S95.  Talamon  :  Appendicite  et  Pe'ri- 
typhlite,  Paris,  1892.  Treves :  Allbutt's  System  of  Medicine,  vol.  iii.. 
p.  879  et  seq.  Tubby :  Appendicitis,  London,  1900.  J.  M.  Van  Cott, 
junior,  ibid.  Wassermann :  Miinchener  Medicinische  Wochenschrift, 
Nos.  17  and  18,  1902. 


202  THE   INTESTINAL  TRACT 

Anomalous  Appendix  Cases 

What  is  included  under  this  term  are  the  cases  in  which 
a  wrong  diagnosis  has  been  made  or  a  wrong  view  is  included 
in  a  right  diagnosis.  In  the  abdomen,  perhaps  more  than 
in  other  regions  of  the  body,  clear  thinking  and  unambiguous 
language  are  highly  desirable.  Wrong  names  not  infre- 
quently mean  wrong  views  ;  and  when  they  do  not  the 
words  mislead  and  give  rise  to  unnecessary  controversy. 
The  first  of  the  anomalies  which  may  be  referred  to  is  what 
has  been  called  "  appendix  dyspepsia." 

Appendix  Dyspepsia.  —  That  chronic  trouble  in  the 
appendix  may  reflexly  affect  gastric  function  would  be 
difficult  to  deny  absolutely.  It  would,  however,  be  less 
difficult,  I  think,  to  advance  evidence  that  dyspepsia  can  lead 
to  appendix  trouble,  manifested  by  local  tenderness,  which 
disappears  when  the  gastric  condition  is  corrected.  What  I 
specially  want  to  represent  here  is  that  pain  or  discomfort 
referred  to  the  epigastrium  is  not  necessarily  dyspepsia, 
and  that,  when  it  is  present  along  with  a  tender  caecum,  the 
term  can  be  whoUy  misleading.  That  dyspepsia  and  a 
tender  caecum  may  be  contemporary  there  is  no  doubt,  but 
when  this  is  found  it  must  not  be  assumed  that  the  removal 
of  the  appendix  is  to  cure  the  dyspepsia.  In  that  direction 
lies  disappointment  and  sometimes  discredit.  Even  opera- 
tion misleads  in  another  way,  which  has  its  own  special 
significance,  namely,  that  the  mere  opening  of  the  abdomen, 
without  doing  anything  else,  may  remove  symptoms  for  a 
considerable  period  of  time.  Many  illustrations  of  this 
might  be  given.  The  latest  case  was  a  patient,  who  had 
been  treated  for  recurring  hyperchlorhydria,  who  took 
acute  appendix  trouble  which  required  the  removal  of  the 
appendix.  For  several  months  he  was  entirely  free  from 
gastric  trouble,  and  the  hope  was  entertained  that  the  cure 
was  to  be  permanent  as  the  malady  had  apparently  been 
"  appendix  dyspepsia."  The  stomach  symptoms,  however, 
slowly  began  to  reappear  and  had  fully  reasserted  themselves 
in  six  months.     The  essential  point  in  all  cases  is  to  be  able 


ANOMALOUS   APPENDIX   CASES  203 

to  recognize  that  there  is  appendix  trouble  behind  a  patient's 
complaint  of  "  indigestion,"  "  flatulence,"  "  constipation," 
and  so  forth.  The  opinion  that  "  dyspepsia  "  is  due  to  the 
appendix  may  be  totally  wrong,  but  it  is  not  comparable 
in  gravity  to  the  mistake  of  diagnosing  an  appendix  as  a 
duodenal  ulcer,  as  colitis,  or  as  dyspepsia. 

The  following  deals  with  this  aspect  of  the  subject  more 
concreteh'. 

Cases  are  met  with  in  which  the  patient  complains  of 
pain,  referred  to  the  epigastrium,  coming  on  after  taking 
food.  The  interval  between  the  meal  and  the  onset  of  the 
pain  may  vary  from  an  hour  to  two  hours,  but  may  be 
shorter.  On  examination  there  may  be  no  evidence  of 
gastric  dilatation,  or  of  retention,  and  relief  of  pain  is  not 
secured  by  the  administration  of  an  alkali  as  is  usual  in 
hyper-acidity.  On  general  examination  of  the  abdomen 
it  is  found  that  there  is  some  tenderness  in  the  caecal  region  ; 
the  tenderness  is  definite,  and  is  judged  of  by  the  effect  of 
an  equal  amount  of  pressure  apphed  over  other  parts  of  the 
colon.  Every  time  the  caecal  region  is  palpated  the  tender- 
ness is  elicited,  so  that  there  remains  no  doubt  as  to  its 
presence.  The  caecum  itself  may  be  felt  to  be  distended. 
This  in  itself  might  not  lead  to  the  conclusion  that  there  was 
any  direct  connection  between  the  epigastric  pain  and  the 
caecal  tenderness,  bu  t  in  the  class  of  case  under  consideration 
it  has  been  noted  that  when  the  local  tenderness  is  brought 
out  by  palpation  pain  is  at  the  same  time  referred  to  the 
epigastrium,  and  the  patient  may  volunteer  the  information 
that  the  kind  of  pain  and  the  site  of  it  are  the  same  as  had 
been  complained  of.  Under  these  circumstances  it  is  reason- 
able to  regard  the  caecal  region  as  the  seat  of  disturbance, 
and  the  caecum  may  be  taken  as  implying  the  appendix.  If 
in  spite  of  keeping  the  caecum  well  cleared  of  excrement  the 
pain  and  tenderness,  but  particularly  tenderness,  persist, 
it  is  desirable  to  have  the  appendix  removed,  and  of  course 
any  ileocaecal  difficulty  from  a  band  relieved  at  the  same 
time.  The  rehef  to  the  symptoms  is  not  always  as  im- 
mediate as  might  be  expected,  but  this  need  not  cause  undue 


204  THE    INTESTINAL  TRACT 

disappointment.  If  continued  attention  is  given  to  the 
regular  clearing  of  the  colon  the  sensory  reflex  which  had 
established  itself  is  finally  controlled,  and  the  fact  that  the 
appendix  can  no  longer  be  a  source  of  anxiety  materially 
aids  in  the  breaking  of  the  nervous  reflex. 

The  following  cases  illustrate  the  points  upon  which 
emphasis  has  been  laid  : — 

Patient  sent  to  Hospital  as  an  Obscure  Stomach  Case 

Case  47. — John  P.,  aged  38,  miner,  was  sent  in  as  a 
stomach  case  which  had  resisted  treatment.  When  asked 
what  he  complained  of  the  answer  was  "  swelhng  of  the 
stomach  and  pain."  The  history  given  was  that  he  had 
been  troubled  with  flatulence  all  his  hfe.  For  seven  or  eight 
years  he  had  suffered  from  "  swelhng  of  the  stomach  and 
pain,"  which  usually  came  on  when  he  had  left  the  house 
after  having  had  dinner,  and  lasted  for  half  an  hour.  For 
the  last  six  months  the  sj^mptoms  had  been  getting  worse. 
On  asking  him  to  place  his  hand  on  the  part  of  the  abdomen 
where  he  felt  the  pain  he  put  it  over  the  middle  region,  that 
is  the  level  of  the  umbiUcus,  and  indicated  that  it  went 
across  the  abdomen  at  that  level.  The  pain  was  not 
definitely  related  to  the  taking  of  food.  On  examination 
the  stomach  was  not  enlarged,  and  there  was  no  tenderness 
in  the  upper  half  of  the  abdomen  either  on  superficial  or 
on  deep  pressure.  The  pain  was  thus  neither  gastric  nor 
duodenal.  Continuing  the  methodical  examination,  by 
palpation  it  was  found  that  on  deep  palpation  of  the 
caecal  region  there  was  a  definitely  tender  area  of  hmited 
extent,  and  that  whenever  the  fingers  were  brought  back 
to  this  point  tenderness  was  ehcited.  There  was  no  other 
tender  point  in  the  abdomen.  After  a  httle  he  told  us 
in  answer  to  a  question  that  the  pain  produced  by  pressure 
went  up  towards  the  navel.  He  was  treated  with  colon 
lavage  once  a  day  for  eight  days,  and  given  a  laxative  pill 
of  cascara,  belladonna,  and  nux  vomica.  The  tenderness 
entirely  disappeared,  and  he  left  hospital  quite  well,  and 
with  instructions  to  be  attentive  to  his  bowels. 


ANOMALOUS   APPENDIX   CASES  205 

Appendix    Simulating    Dyspepsia  :     Sensory    Reflex 

Persisting 

Case  48. — Miss  M,,  aged  31,  was  sent  to  me  by  a  medical 
relative  of  her  own,  who  reported  that  from  being  a  bright 
and  merry  girl  she  had  become  listless,  morbid,  and  imagina- 
tive about  herself.  The  bowels  tended  to  be  stiff,  there 
was  a  history  of  abdominal  pains,  and  of  pain  in  the  back. 
The  only  objective  observation  with  regard  to  the  abdomen 
was  that  the  succussion  splash  of  the  stomach  reached  to 
the  level  of  the  umbilicus,  and  showed  some  dilatation  with 
ptosis  of  the  lower  border.  The  diet  was  regulated  and  the 
gastric  and  intestinal  conditions  were  attended  to,  but 
without  much  improvement.  After  a  considerable  interval 
of  time  I  again  saw  her  after  she  had  had  a  somewhat  severe 
attack  of  abdominal  pain.  At  this  time  there  was  definite 
tenderness  in  the  right  ihac  region,  and  pressure  there  caused 
pain  in  the  upper  half  of  the  abdomen.  The  history  of  this 
attack  left  no  doubt  in  my  mind  that  it  was  to  be  attributed 
to  the  appendix,  and  that  instead  of  having  a  gastro- 
enterostomy performed,  the  first  step  to  be  taken  was  to 
have  the  appendix  removed.  Mr.  Wallace  saw  her  -with  me 
and  her  medical  relative,  and  endorsed  our  view.  The 
operation  was  carried  through  without  anxiety,  and  the 
patient  made  a  good  recovery.  It  was,  however,  a  number 
of  months  before  the  effect  of  the  operation  became  definitely 
estabUshed,  and  she  began  to  regain  her  earlier  health  and 
vigour. 

Appendix  Diagnosed  as  Duodenal  Ulcer 

Case  49.— Mr.  H.  F.,  a  student  at  one  of  the  English 
colleges,  had  suffered  from  attacks  of  abdominal  pain  for 
a  few  years.  He  had  been  in  London  for  a  medical  opinion, 
and  the  opinion  was  that  he  had  a  duodenal  ulcer.  I  saw 
him  as  he  was  recovering  from  an  attack  similar  to  previous 
attacks,  and  I  failed  to  ehcit  any  facts  to  indicate  the 
existence  of  such  an  ulcer.  There  was,  however,  tenderness 
in  the  caecal  region  ;   but  it  was  brought  out  onl}'  on  deep 


2o6  THE  INTESTINAL  TRACT 

pressure  through  the  caecum.  The  diagnosis  in  my  judg- 
ment was  recurring  appendicitis,  with  the  appendix  situated 
retrocsecall}'.  I  suggested  that  he  ought  to  be  watched 
carefully,  with  a  view  to  testing  the  accuracy  of  this  opinion, 
and,  were  it  found  to  be  correct,  the  appendix  ought  to  be 
removed  without  delay.  The  patient  was  the  son  of  a 
medical  man,  and  this  was  fully  attended  to.  In  the  course 
of  a  week  or  two  he  had  another  attack,  and  there  was  no 
doubt  as  to  its  character,  and  surgical  help  was  at  once 
summoned.  The  appendix,  situated  as  had  been  stated, 
was  removed  by  Mr.  Miles.  An  excellent  recovery  took 
place  ;  the  symptoms  entirely  disappeared ;  the  patient 
put  on  considerable  weight,  and  he  was  able  to  resume  his 
studies  with  renewed  vigour,  and  has  continued  free  from 
abdominal  trouble. 


Appendix  Diagnosed  as  Colitis 

Case  50. — Mr.  L.  E.,  aged  ig,  preparing  to  become  an 
undergraduate  at  one  of  the  Enghsh  Universities,  was  sent 
to  me  for  advice.  The  history  was  of  recurring  attacks  of 
pain  in  the  abdomen  which  were  stated  to  be  due  to  "  cohtis," 
from  which  he  had  recently  suffered  and  was  stiU  suffering. 
In  the  morning  of  the  afternoon  on  which  he  was  brought  to 
me  he  had  had  a  specially  severe  attack  of  pain,  and  had 
himself  suggested  seeing  an  Edinburgh  physician.  On 
examining  the  abdomen  the  stomach  was  found  to  be  normal, 
and  there  was  no  tenderness  along  the  course  of  the  colon  ; 
but  at  the  caecum,  on  deep  pressure,  pain  could  be  alwaj'S 
ehcited,  it  could  also  be  elicited  b}'  bimanual  palpation. 
I  expressed  the  opinion  that  the  seat  of  the  trouble  was 
the  appendix,  and  that  it  was  situated  retrocaecally.  I 
represented  the  danger  of  allowing  such  a  condition  to 
continue  ;  that  it  might  become  acute  at  any  time,  and  even 
if  it  did  not  do  so  there  would  be  recurring  attacks  of  pain, 
which  v.'ould  certainlj-  interrupt  his  studies.  ]\Ir.  Stiles 
removed  the  appendix,  which  was  found  lying  behind  the 
caecum  and  stretching  far  up  behind  the  ascending  colon. 


ANOMALOUS   APPENDIX   CASES  207 

Appendix  Diagnosed  as  Gall-stone  Colic 

Case  51. — James,  S.  This  patient  was  admitted  to  my 
ward  with  a  history  of  a  severe  attack  of  abdominal  pain 
which  was  diagnosed  as  biUary  cohc.  On  examination  there 
was  no  tenderness  in  the  region  of  the  gall-bladder,  but  there 
was  pronounced  tenderness  in  the  csecal  region,  and  on  going 
more  fully  into  the  history  it  was  evident  that  the  attack 
referred  to  had  been  due  to  the  appendix  and  not  to  the 
gall-bladder.  The  patient  was  transferred  to  the  surgical 
house  and  had  his  appendix  removed  successfully. 

Appendix  Diagnosed  as  Duodenal  Ulcer  :  Double 
Operation  :  a  Freak  Appendix 

Case  52.^This  case  can  only  be  referred  to  briefly. 
The  patient  had  suffered  from  recurring  attacks  of  abdominal 
pain  which  led  to  a  provisional  diagnosis  of  duodenal  ulcer. 
The  abdomen  was  opened,  but  as  the  duodenum  was  found 
to  be  sound  nothing  further  was  done.  The  symptoms 
continued  as  they  were  before  the  laparotomy,  and  I  had  the 
opportunity  of  examining  the  patient.  The  only  objective 
sign  was  the  presence  of  a  limited  area  of  tenderness  on  the 
edge  of  the  liver  in  the  position  of  the  gall-bladder.  This 
and  the  recurring  attacks  of  pain  suggested  biliary  colic 
with  a  tender  gall-bladder,  but  when  the  abdomen  was 
opened  it  had  been  examined  and  found  to  be  sound  and  no 
stone  in  it.  The  late  Dr.  Price,  from  X-ray  appearances 
at  the  caecum,  held  that  the  appendix  was  not  right ;  but 
what  connection  could  exist  between  that  and  the  pain 
and  tenderness  in  the  hepatic  region  appeared  to  be  inexplic- 
able. The  patient,  however,  had  suffered  so  much  that  he 
insisted  on  having  the  appendix  removed.  The  abdomen 
was  again  opened  with  this  object  in  view  and  when  it  was 
reached  it  was  found  to  be  of  great  size  and  ran  upwards 
so  far  that  its  tip  reached  the  liver  edge,  to  which  it  was 
firmly  attached  at  the  point  where  tenderness  could 
always  be  elicited.  The  patient  made  an  excellent  recovery, 
but  the  recurring  pains  were  slow  in  disappearing. 


2o8  THE   INTESTINAL  TRACT 


Calculus  in  Ureter  mistaken  for  Appendicitis 

Cases  53. — Cases  of  this  description  wiU  be  recorded  in  the 
chapter  on  renal  calculus,  and  the  subject  does  not  require 
further  consideration  here. 


C^cAL  Tenderness  accompanying  Influenza 

Case  64. — This  combination  of  S3^mptoms  presents  an 
anxious  and  a  difficult  problem.  The  combination  may  be 
present  at  the  first  visit  of  the  family  practitioner.  It  occurs 
at  a  time  when  mild  cases  of  influenza  are  prevalent  and  the 
S3^mptoms  would  warrant  the  simple  diagnosis  M^ere  it  not 
that  the  careful  medical  man  finds  a  tender  caecum.  This 
local  tenderness  \vith  considerable  elevation  of  temperature 
at  once  raises,  in  an  acute  form,  the  question  whether  the 
patient  is  not  suffering  from  a  very  acute  appendix  and  not 
at  all  from  influenza.  I  have  advised  the  removal  of  an 
appendix  under  these  circumstances,  both  in  hospital  and 
in  private,  and  the  operation  has  been  carried  through 
successfully,  but  mthout  producing  any  effect  upon  the 
temperature  or  the  general  sjonptoms.  These  ran  on  for 
a  week  or  more  as  a  mild  influenza  after  which  rapid  recovery 
took  place.  I  have  seen  an  approximately  similar  case 
where  the  same  problem  presented  itself  in  the  course  of  a 
few  daj^s  after  the  onset  of  a  mild  influenza.  In  a  few  more 
days  it  was  clear  to  all  concerned  that  the  removal  of  the 
appendix  was  imperative.  The  patient  made  a  good 
recovery. 

Conclusions  and  Summary 

This  subject  is  so  important  that  it  may  be  useful  to 
briefly  summarize  what  has  been  written  and  to  indicate 
clearly  the  conclusions  the  writer  has  reached  after  years 
of  experience  of  hospital  and  of  private  practice,  and  of  the 
mistakes  which  may  be  made. 

The  important  part  played  by  hindrance  to  drainage  of 
the  appendix  has  been  estabhshed  by  careful  clinical  and 


CONCLUSIONS  AND    SUMMARY  209 

pathological  observation,  and  has  more  recently  been  con- 
firmed by  X-ray  examination. 

Sufficient  drainage  may  follow  upon  (i)  swelling  of  the 
mucous  coat  of  the  caecum  or  the  retention  of  faeces  there ; 
and  (2)  on  the  anatomical  position  and  character  of  the 
appendix  itself. 

If  there  is  recurring  difficulty  in  its  emptying,  attacks 
of  pain  occur,  which  were  early  spoken  of  as  appcndictilar 
colic.  These  cases  may  ultimately  have  a  severe  attack, 
such  as  Mr.  Wilkie  described  as  acute  obstruction  of  the 
appendix,  with  rapid  necrosis,  gangrene  and  perforation. 

There  is  no  doubt  that  it  is  round  this  question  of  drain- 
age that  mistakes  and  misconceptions  are  most  frequent. 
Inefficient  drainage  readily  sets  up  more  or  less  irritation 
in  the  wall  of  the  appendix.  When  this  has  taken  place, 
in  however  small  a  degree,  a  point  or  small  area  of  tender- 
ness can  be  found  by  careful  and  proper  palpation  of  the 
caecal  region.  If  the  appendix  is  situated  retrocsecally  the 
tenderness  is  only  made  out  by  deep  and  gentle  pressure 
exercised  through  the  interposed  caecum  ;  if  the  appendix 
so  situated  is  a  long  one  the  tenderness  may  only  be  made 
out  above  the  level  of  the  caecum  behind  the  ascending 
colon.  In  these  cases,  and  they  are  fairly  common,  the 
recurring  attacks  of  pain  and  the  Hmited  area  of  tenderness 
are  phenomena  quite  inconsistent  with  a  diagnosis  of 
colitis,  and  that  is  the  only  condition  with  which  an  imperfect 
or  hurried  examination  could  reasonably  confuse  it.  In  a 
few  cases  the  appendix  hangs  down  into  the  true  pelvis  and 
tenderness  may  be  found  only  on  rectal  examination ;  or 
tenderness  may  be  elicited  indefinitely  by  palpating  from 
the  surface  and  be  very  pronounced  on  rectal  examination 
when  the  finger  is  pressed  towards  the  caecum. 

There  is  no  doubt  that  appendicular  colic  may  be  caused 
by  constipation  and  retention  of  faeces  in  the  caecum ;  and 
that  this  type  of  disorder  can  be  removed  and  prevented  < 
by  getting  the  bowels  properly  regulated.  Such  appendicular 
colic  is  not,  however,  usually  severe ;  there  is  only  slight 
tenderness,  and  no  rise  of  temperature. 

14 


210  THE   INTESTINx\L  TRACT 

In  this  tj^pe,  however,  there  may  be  and  often  is  recur- 
rence of  attacks,  with  pain,  some  tenderness  on  deep  pres- 
sure, but  no  rise  of  temperature.  This  is  a  dangerously 
insidious  t3^pe  ;  it  often  leads  the  victim  to  think  that  he 
is  suffering  "  only  from  indigestion  "  or  from  cohc  due  to 
constipation,  for  he  can  remove  it  by  taking  a  dose  of  some 
aperient  medicine  ;  and  this  may  go  on  until  a  severe  attack 
leads  to  the  doctor  being  sent  for.  This  severe  attack 
means  a  more  pronounced  obstruction,  and,  with  the  history 
which  I  have  indicated  behind  it,  the  appendix  ought  to  be 
removed  without  an  hour's  unnecessary  delay. 

In  cases  of  this  recurring  type  the  fact  to  realize  fully 
is  that  the  true  significance  of  recurrence  is  that  we  are 
in  face  of  an  appendix  whose  drainage  is  easily  interrupted. 
It  may  be  due  to  one  of  several  possible  conditions,  which 
particular  one  need  not  concern  us  ;  the  important  fact  is 
the  recurrence  of  interrupted  drainage.  Such  cases  may 
never  have  a  really  severe  attack,  and,  after  many  attacks, 
may  cease  altogether.  On  the  other  hand,  the  big  attack 
may  come  at  any  time  and  at  the  most  awkward  and 
unfortunate  time,  and  every  one  interested  is  faced  with 
possible  tragedy.  My  own  settled  conviction  is,  and  my 
teaching  has  long  been  this,  that  an  appendix  of  the  type 
indicated  ought  always  to  be  removed,  as  soon  as  necessary 
arrangements  can  be  made. 

When  pain  is  sudden  and  severe  in  onset  it  must  be 
borne  in  mind  that  acute  appendix  obstruction  has  almost 
certainly  occurred,  and,  if  that  is  not  overcome  in  twelve 
hours,  time  is  given  for  the  heightening  of  the  virulence  of 
the  imprisoned  micro-organisms  to  be  speedily  followed  bj/ 
intense  inflammation,  necrosis,  and  gangrene. 

Before  concluding  this  summary  there  may  be  included 
in  it  the  results  of  years  of  experience  in  the  use  of  colon 
lavage,  in  this  as  well  as  in  other  abdominal  conditions,  as 
Professor  Bourget  of  Lausanne  used  it,  and  which  is  referred 
to  in  the  introductory  part  of  this  chapter.  As  to  the 
safety  of  this  proceeding  there  is  no  question.  As  to  its 
efficacy  in  clearing  out  the  colon  and  cleaning  the  csecum 


CONCLUSIONS   AND    SUMMARY  211 

increased  experience  has  strengthened  first  impressions. 
Under  this  treatment  a  tender  appendix  may  rapidly  lose 
its  tenderness  and  if  this  does  not  take  place  operative 
interposition  becomes  more  clamant.  The  effect  of  colon 
lavage  has  been  very  striking  in  cases  coming  into  the  wards 
as  acute  abdomens  with  pain,  rigidity,  and  tenderness  all 
over  the  abdomen.  If  colon  lavage  is  at  once  resorted  to  and 
repeated  every  hour  or  two,  the  surface  hyperaesthesia 
rapidly  diminishes  and  permits  of  free  palpation.  The 
procedure  is  of  great  assistance  in  some  obscure  cases  when 
the  surgeon  is  not  willing  to  open  the  abdomen  until  an  effort 
is  made  to  reach  a  reasonable  diagnosis. 


CHAPTER  XVIII 

INTESTINAL   OBSTRUCTION  :    MALIGNANT   DISEASE   OF 
RECTUM  :    ENTEROSPASM 

Intestinal  obstruction  may  be  caused  by  a  variety  of 
conditions.  The  first  condition  which  ought  to  be  thought 
of  and  examined  for  is  strangulation  of  an  external  hernia. 
The  importance  of  this  is  not  to  be  underestimated,  for  the 
neglect  of  it  in  children  as  well  as  in  adults  ends  in  tragedy 
if  not  corrected  in  time.  Internal  hernia  may  occur  of 
any  part  of  the  intestine  and  is  characterized  by  sudden 
onset  of  pain,  referred  commonly  to  the  site  of  the  hernia, 
and  early  onset  of  vomiting.  Such  cases  require  prompt 
surgical  intervention.  And  the  physician  does  not  see 
many  of  them.  In  children  the  possibility  of  intussusception 
has  to  be  remembered  and  its  special  features  recognized 
when  present.  Many  years  ago,  before  the  advent  of  general 
abdominal  surgery,  I  attended  a  fatal  case  of  obstruction, 
caused  by  a  large  gall-stone  which  had  ulcerated  out  of  the 
gall-bladder.  The  stone  had  stuck  in  the  small  intestine 
at  the  point  where  pain  was  present. 

The  cases  to  which  special  reference  is  here  directed  are 
of  a  different  type,  in  the  circumstance  of  their  providing 
a  history  of  intestinal  difficulty  before  there  is  definite  or 
complete  obstruction,  meaning  thereby  an  obstruction 
which  has  not  been  relieved  by  medicinal  measures  in  common 
use.  They  include  the  cases  of  organic  stricture  in  the 
intestine.  The  small  intestine  is  practically  exempt  from 
such  stricture.  The  large  intestine,  on  the  other  hand, 
is  frequently  affected.  The  symptoms  and  signs  of  obstruc- 
tion will  be  dealt  with  later.  It  may,  however,  be  stated 
now  that  stricture  of  the  large  intestine  is  practically  always 


INTESTINAL   OBSTRUCTION  213 

malignant,  although  the  degree  of  malignancy  varies  in 
individual  cases.  Stricture  as  a  rule  is  confined  to  one 
of  several  definite  parts  of  the  colon.  The  parts  which  may 
be  affected  are  the  caecum,  the  hepatic  flexure,  the  splenic 
flexure,  and  the  pelvic  colon  (the  sigmoid  flexure)  where  it 
joins  the  colon  and  the  rectum.  The  rectum  itself  may  be 
the  seat  of  primary  malignant  disease.  All  these  regions 
can  be  effectively  examined  by  the  ordinary  methods  of 
physical  examination.  That  the  regions  mentioned  are  the 
usual  sites  of  stricture  narrows  the  field  of  investigation, 
and  when  the  position  of  a  stricture  has  been  determined, 
and  the  fact  realized  that  it  must  be  assumed  to  be  maUg- 
nant,  the  call  for  expert  surgical  assistance  will  not  be 
postponed  indefinitely  It  is  one  of  the  conditions  in 
which  early  diagnosis  and  early  operation  give  highly 
satisfactory  results.  Waiting  until  a  definite  tumour 
mass  is  felt,  or  until  there  is  complete  obstruction,  is  very 
crude  medicine.  When  complete  obstruction  supervenes, 
it  is  due  either  to  a  blockage  by  hard  fseces  or  to  spasm  at 
the  seat  of  lesion. 

Symptoms  and  Signs. — There  may  be  discomfort  com- 
plained of  and  referred  to  any  one  of  the  regions  specified  ; 
there  may  be  tenderness,  but  it  may  be  absent.  There  is 
usually  a  history  of  difficulty  with  the  bowels,  of  recurring 
periods  of  constipation  requiring  increasing  doses  of  purga- 
tives for  relief.  There  may  or  may  not  be  pain.  On 
examining  the  abdomen,  if  the  art  of  palpation  has  been 
acquired,  it  will  be  found  that  the  colon  is  full  behind  the 
seat  of  the  stricture  and  empty  beyond  it.  If  the  caecum 
be  the  seat  of  obstruction  the  condition  has  often  lasted 
long  enough  to  have  produced  a  palpable  swelling  or  tumour 
mass,  and  the  peristaltic  movements  of  the  small  intestine 
may  be  visible.  In  the  other  regions  the  stricture  often 
belongs  to  the  annular  type,  whereas  this  type  is  perhaps 
not  common  at  the  caecum.  When  the  stricture  is  at  the 
junction  of  the  sigmoid  flexure  and  rectum  it  can  be  felt  by 
a  long  finger,  and  the  mass  of  faeces  above  it  may  be  mistaken 
for  a  neoplasmic  mass. 


214  THE   INTESTINAL  TRACT 

]\Iany  attacks  of  such  temporary  obstruction  may  be 
overcome  by  means  of  strong  purgatives  and  the  dihgent 
use  of  the  enema  syringe  ;  but  the  patients  ultimately 
land  in  the  surgeon's  hands  ;  often  when  the  conditions  are 
highl}^  unfavourable,  and  when  removal  of  the  part  cannot 
be  attempted.  Clear  diagnosis  at  an  early  stage,  and  the 
recognition  of  the  fact  that  stricture  is  presumably  mahg- 
nant,  would  lead  to  mse  counsel  being  given  to  a  patient 
at  an  early  date.  Waiting  for  a  tumour  to  be  felt,  or  for 
complete  obstruction,  ought  to  be  relegated  to  the  methods 
of  a  past  time. 

The  following  case  and  the  remarks  made  on  it  formed 
part  of  a  clinical  lecture  on  the  subject  dealt  with  in  this 
chapter. 

Chronic  Obstruction  :  Adhesions,  Splenic  Flexure 

OF  Colon 

Case  65. — James  McG.,  aged  41,  labourer  in  iron  works, 
was  admitted  on  the  17th  September,  1915,  complaining 
of  pain  in  stomach  (abdomen)  and  vomiting.  The  history  he 
gave  was  that  four  5''ears  before,  without  previous  symptoms, 
he  began  to  vomit  everything  he  swallowed  except  milk 
and  switched  egg.  He  was  troubled  also  with  flatulence. 
He  did  not  usually  have  pain  after  eating,  but  pain  came  on 
with  the  wind  or  vomiting.  The  first  attack  lasted  for  a 
month.  For  three  months  after  that  he  could  eat  anything 
without  trouble;  he  then  had  another  attack  of  the  same 
kind,  which  lasted  for  nine  days  ;  and  these  attacks  had 
recurred  at  irregular  intervals  up  to  the  time  of  admission. 
The  attack  for  which  he  was  admitted  had  lasted  for  two 
weeks,  and  for  the  last  five  days  of  this  period  he  had  vomited 
everything  he  took,  including  milk.  The  vomit  was  some- 
times green,  at  other  times  brown,  "  like  tea."  He  said 
that  he  had  lost  3  st.  in  weight  during  the  last  few  years. 
He  was  unmarried  ;  he  had  syphiUs  twenty  years  ago  ;  he 
used  to  drink  rather  heavily  until  four  years  ago,  and  he 
attributed  his  recurring  attacks  to  his  past  habits  in  this 
respect. 


INTESTINAL    OBSTRUCTION  215 

Condition  on  Admission. — He  looked  fairly  well  nourished, 
but  his  weight  was  only  7  st.  yl  lbs.  and  his  height 
5  ft.  3  ins.  The  abdominal  pain  was  referred  to  the  left 
hypochondrium  and  was  always  very  severe  after  vomiting. 
There  was  constipation,  the  bowels  not  having  acted 
for  six  days.  That  the  abdominal  pain  was  not  gastric  in 
origin  was  shown  by  the  following  facts  :  (1)  in  the  intervals 
between  the  attacks  pain  was  not  brought  on  by  taking 
ordinary  food  ;  (2)  when  the  attacks  were  on,  taking  milk 
even  would  bring  on  pain  and  vomiting  ;  (3)  the  pain  was 
not  relieved  but  was  intensified  by  the  vomiting.  On 
inspection  of  the  abdomen  there  were  no  abnormal  appear- 
ances, and  abdominal  respiratory  movement  was  free. 
On  palpation  there  was  pain  in  the  left  hypochondrium 
on  pressure  over  the  lower  ribs,  and  also  tenderness 
on  deep  palpation  in  the  left  loin.  The  treatment 
adopted  was  colon  lavage  every  four  hours.  The  water  was 
allowed  to  flow  in  from  a  douche  can,  a  syringe  not  being 
employed.  The  result  was  that  the  colon  was  rapidly 
emptied  and  the  sickness  and  pain  stopped.  On  the  22nd, 
he  was  given  a  pill  containing  cascara,  belladonna  and 
nux  vomica,  but  the  lavage  was  returned  to  from  time  to 
time.  The  bowels  were  difficult  to  get  into  good  working 
order.  Liquid  paraffin  was  tried  in  addition  to  cascara, 
compound  jalap  powder  was  resorted  to,  and  even  croton 
oil  in  quarter-drop  doses  was  given,  all  with  unsatisfactory 
results,  and  colon  lavage  had  to  be  resorted  to.  This  went 
on  until  the  26th  October,  when  in  addition  to  the  increasing 
difficulty  in  getting  the  bowels  to  move  severe  vomiting 
supervened,  which  continued  day  and  night.  The  symptoms 
clearly  indicated  intestinal  obstruction,  but,  as  this  was 
not  the  first  attack  of  the  kind  he  had  had,  we  decided  to 
have  him  X-rayed  before  sending  him  for  operation.  The 
large  dose  of  bismuth  necessary  for  this  procedure  stopped 
the  vomiting  for  a  time,  but  it  recurred.  The  screen  examina- 
tions showed  a  definite  blockage  at  the  splenic  flexure. 
Professor  Caird  kindly  saw  him  with  me,  and  the  patient 
was   transferred   to   his   ward  for   operation.     Fortunately 


2i6  THE    INTESTINAL  TRACT 

there  ^^•as  nothing  more  serious  than  adhesions  which 
only  required  to  be  released.  The  patient  made  a  good 
recovery. 

Remarks. — This  case  illustrates  a  type  of  abdominal 
case  which  is  not  very  rare,  and  which  it  is  of  much  import- 
ance you  should  be  able  to  recognize.  I  have  often  impressed 
upon  you  the  fact  that  you  require  to  know  the  changes 
which  may  be  present,  to  visualize  them  mentally,  before 
you  can  reach  a  sound  diagnosis.  You  cannot  diagnose 
a  malady  unless  you  recall  the  possibiUty  of  its  presence. 
The  class  which  this  case  typifies  is  what  we  may  call 
recurring  intestinal  obstruction  due  to  a  local  interference 
with  the  mobihty  or  the  lumen  of  the  intestine.  Inter- 
ference with  normal  mobihty  at  a  flexure,  such  as  seems  to 
have  been  present  in  this  case  at  the  splenic  flexure,  would 
appear  to  lead  to  obstruction  after  a  period  of  constipation. 
The  colon  contents  get  piled  up  behind  the  affected  point, 
and  symptoms  of  complete  obstruction  supervene,  with, 
however,  the  absence  of  one  important  symptom,  namely, 
early  pain.  The  absence  of  early  and  severe  local  pain 
excludes  such  causes  of  acute  obstruction  as  hernia,  which 
demands  immediate  surgical  interference.  The  question, 
however,  which  requires  constant  consideration,  in  the 
cases  where  the  symptoms  of  obstruction  are  pronounced, 
is  :  How  long  is  it  safe  to  persevere  with  the  various  means 
at  our  disposal  which  are  directed  to  the  reUef  of  the  obstruc- 
tion ?  In  some  cases,  where  operation  would  be  determined 
on,  and  yet  from  some  circumstance  is  not  feasible.  Nature, 
aided  by  medical  measures,  ultimately  removes  the  block 
and  the  patient  again  enters  on  a  period  of  time  during  which 
the  bowels  can  be  kept  going  with  ordinary  laxatives. 
Our  decision  on  the  question  of  operation  is  really  largely 
dependent  upon  our  mental  visuaUzing  of  the  local  condi- 
tion ;  and  here  the  fundamental  consideration  is  :  Is  the 
obstruction  malignant  or  not  ?  Some  cases  give  a  history 
of  constipation  which  has,  up  to  a  certain  point,  been 
successfully  overcome  by  the  measures  adopted  by  the 
patient  himself,  perhaps  with  the  assistance  of  his  ordinary 


INTESTINAL   OBSTRUCTION  217 

medical  attendant  ;  but  a  time  comes  when  the  constipation 
does  not  yield  to  the  measures  which  have  hitherto  been 
sufficient  and  to  this  symptom  the  additional  symptom  of 
vomiting  is  added.  When  the  abdomen  is  examined  it  is 
found  that  there  is  a  localized  sweUing  with  local  tenderness. 
Cases  of  this  kind  are  so  commonly  malignant  that  they 
must  be  assumed  to  be  so,  unless  facts  are  available  which 
weaken  the  assumption.  In  such  cases  even  when  the 
symptoms  of  complete  obstruction  are  pronounced,  rehef 
may  be  obtained  without  operation  ;  and  temporizing  is 
permissible  if  the  local  condition  is  so  pronounced  that  there 
is  no  hope  of  complete  removal  of  the  involved  part  being 
possible.  All  that  surgery  can  do  in  these  cases  is  to  estabhsh 
an  outlet  for  the  bowel  contents  on  the  proximal  side  of  the 
obstruction,  and  thereby  remove  the  symptoms  of  obstruc- 
tion. The  obstruction  is  not  removed  but  the  operation  is 
a  valuable  measure  of  amehoration.  It  is  frequently  one's 
experience  in  consulting  practice  as  weU  as  in  hospital 
practice  that  when  the  case  is  first  seen  the  condition  is 
such  as  is  here  indicated. 

This,  however,  leads  to  the  consideration  of  the  very 
practical  question  of  the  recognition  of  a  local  and  hmited 
point  of  obstruction  before  it  has  advanced  so  far  as  is 
portrayed  above.  In  this  connection  it  must  be  empha- 
sized that,  when  constipation  is  a  marked  s^Tnptom,  the 
efficient  examination  of  the  abdomen  ought  always  to  be 
undertaken.  When  there  is  evidence  that  the  obstruction 
is  in  some  definite  region  as  the  rectum,  splenic  or  hepatic 
flexures,  or  caecum,  the  presumption  is  so  strong  that  it  is 
malignant  that  advice  to  have  it  dealt  with  surgically  ought 
to  be  tendered.  At  the  early  stage  the  surgeon  will  probably 
be  able  to  completely  remove  the  affected  parts  and  to 
estabhsh  an  effective  anastomosis. 

In  the  particular  case  with  which  we  are  deahng  at 
present  there  was  evidence  that  the  obstruction  was  at  the 
splenic  flexure,  but  we  had  no  evidence  as  to  the  cause  of  the 
obstruction.  The  obstruction  had  recurred  frequently 
during  the  previous  four  years,  with  complete  absence  of 


2i8  THE   INTESTINAL  TRACT 

symptoms  in  the  intervals  of  the  attacks  of  obstruction. 
He  was  under  our  observation  in  hospital  during  a  quiescent 
interval  and  the  most  careful  examination  of  the  abdomen 
revealed  no  tenderness  or  swelling.  When  an  attack  of 
obstruction  supervened  the  seat  of  obstruction  as  shown 
by  local  tenderness  and  swelUng  was  placed  at  the  splenic 
flexure  and  this  was  confirmed  by  X-ray  examination. 
The  presumption  therefore  was  against  malignancy.  At  the 
same  time,  do  not  be  led  away  by  the  academic  aspect  of 
this  diagnosis.  The  essential  points  were  :  (i)  the  recur- 
rence of  intestinal  obstruction  ;  (2)  the  obstruction  was  at 
the  splenic  flexure  ;  (3)  the  obstruction  had  to  be  relieved  ; 
(4)  there  was  no  evidence  of  extensive  involvement,  and  it 
was  hoped  therefore  that  the  surgeon  would  be  able  to 
remove  completely  the  mechanical  difficulty,  I  had  not 
even  thought  of  adhesions  as  the  cause  of  the  obstruction  ; 
but,  as  I  often  point  out  to  you,  in  diagnosis,  especially  in 
the  abdomen,  there  are  practical  questions  and  there  are 
academic  questions,  and  the  foregoing  again  illustrates  this 
distinction.  Yet  even  here,  although  the  immediate 
necessity  was  operation  for  the  relief  of  obstruction,  the 
academic  question  of  malignant  or  non-mahgnant  obstruc- 
tion was  a  very  practical  question,  although  more  remote, 
but  it  could  be  allowed  to  wait  until  the  necessary  opening 
revealed  the  precise  cause. 


The  following  cases  illustrate  the  history  which  may  be 
obtained  from  patients  and  the  physical  signs  which  may  be 
present. 

Colloid  Cancer  of  Part  of  Pelvic  Colon  :  Intussuscjep- 
TioN  OF  Lower  Part  :    Successful  Removal 

Case  56. — John  G.,  aged  60,  was  admitted  on  the  23rd 
September,  complaining  of  diarrhcea  and  pain  in  abdomen. 
The  history  as  given  to  my  Resident  Physician,  Dr.  G.  M. 
Brown,  was  as  follows.   About  twenty  months  ago  he  had  an 


COLLOID   CANCER  OF   PELVIC   COLON       219 

attack  of  ' '  diarrhoea. ' '  His  bowels,  which  prior  to  this  period 
moved  daily,  became  constipated,  and  two  days  later  he  was 
seized  with  a  dull  pain  in  the  left  iliac  region.  The  pain  was 
constant  but  varied  in  severity.  A  few  hours  later  he  began 
to  have  frequent  calls  to  go  to  stool  and  on  every  occasion 
only  a  small  amount  of  slimy  material  mixed  with  red  blood 
was  passed.  This  continued  for  about  a  week  and  dis- 
appeared after  the  passing  of  some  stringy  masses  of  blood- 
stained mucus.  The  bowels,  which  had  been  constipated  for 
ten  days,  then  began  to  move  of  their  own  accord,  and  the 
pain,  which  had  been  gradually  becoming  less,  disappeared. 
There  was  no  vomiting.  He  returned  to  work  as  an  engine- 
man  and  felt  in  his  usual  health.  A  fortnight  before  admission 
the  bowels  again  became  constipated.  He  took  opening 
medicine  without  obtaining  reUef.  Two  days  later  blood 
and  mucus  were  passed  as  on  the  previous  occasion.  A 
week  later  pain  reappeared  in  the  left  iliac  region,  of  the 
same  description  as  before.  The  pain  and  rectal  discharge 
continued  after  admission.  No  fgecal  matter  had  been 
passed  for  fully  two  weeks,  but  much  flatus  had  passed. 
There  was  no  vomiting.  He  stated  that  the  bowels  had 
moved  freely  and  regularly  except  during  the  two  attacks 
mentioned.  He  had  not  noticed  blood  in  the  stools  nor 
any  change  in  the  shape  of  the  formed  material  he  passed. 
For  the  last  month  there  had  been  much  tenesmus  and  he 
often  went  to  stool  without  passing  anything.  He  had  become 
thinner  within  recent  months. 

Examination. — The  abdomen  was  somewhat  distended 
and  tympanitic  and  gurgling  sounds  were  heard.  There 
was  tenderness  in  the  left  iliac  fossa  especially  over  the  colon, 
where  there  was  a  rod-shaped  hard  and  tender  swelling. 
On  rectal  examination  there  was  felt  a  firm  mass  low  down 
in  the  rectum  ;  it  was  freely  movable,  the  finger  could  be 
passed  round  it,  and  at  its  apex  there  was  a  central  depression 
which  did  not  admit  the  linger.  There  was  no  connection 
between  the  mass  and  the  rectal  wall.  The  mass  was 
congested  and  there  was  blood  on  the  examining  finger. 
The  surface  was  smooth  and  not  specially  tender.   The  patient 


220  THE   INTESTINAL   TRACT 

was  transferred  to  Professor  Caird,  who  operated  on  him  on 
September  26th.  The  rod-like  swelling  was  part  of  the 
sigmoid  flexure.  It  was  resected  and  the  cut  ends  united. 
The  mass  in  the  rectum  was  an  intussusception  which  had 
become  reduced  just  before  operation.  The  removed  portion 
was  the  seat  of  a  colloid  cancer.  The  patient  made  a  good 
recovery. 

Obstruction  at  Cecum  :    Successful  Removal 

Case  57. — William  M.,  aged  60,  was  admitted  on  the 
12th  August.  Up  till  two  months  before  admission, 
patient  was  in  good  health.  At  that  time  he  began  to  suffer 
from  constipation,  which  gradually  became  more  marked. 
Prior  to  that  the  bowels  moved  daily.  For  no  apparent 
reason  he  became  constipated  and  after  going  for  three 
days  without  a  motion  he  took  a  dose  of  castor  oil  which 
produced  one  small  motion.  This  was  followed  by  a  week 
without  any  relief.  Epsom  salts  were  taken  without  any 
effect.  Flatus  was  passing  during  this  time.  He  began  to 
have  abdominal  pain  referred  to  the  epigastrium  and  he 
noticed  that  the  abdomen  was  becoming  distended.  He  then 
consulted  his  medical  attendant  and  was  treated  by  enemata. 
These  brought  away  a  large  amount  of  fsecal  matter  and 
gave  much  relief.  Enemata  were  continued  up  to  the  time 
of  admission.  Two  weeks  after  the  enemata  were  begun 
the  distension  and  attacks  of  pain  returned  and  for  a  week 
he  vomited  every  day.  The  quantity  vomited  was  large, 
it  varied  in  colour,  and  had  a  sour  taste.  He  was  then  given 
nutrient  enemata,  and  had  no  more  vomiting.  On  examina- 
tion the  abdomen  was  distended  and  tympanitic.  At  intervals 
of  about  five  minutes  a  wave  of  peristalsis  was  visible  which 
began  in  the  lower  half  of  the  abdomen  on  the  left  side  and 
passed  across  towards  the  caecal  region,  then  up  towards 
the  liver  and  from  there  across  the  upper  part  of  the  abdomen 
to  the  left  side.  This  was  accompanied  by  loud  gurgling 
sounds.  There  was  a  well-marked  "  ladder  pattern." 
Between  these  periods  of  visible  peristalsis  the  abdomen 


STRICTURE  AT   SPLENIC  FLEXURE         221 

was  quite  soft.  There  was  no  lump  to  be  felt  an5rwhere  and 
there  was  no  pam  on  palpation.  The  abdomen  moved 
freely  on  respiration.  Rectal  examination  was  negative. 
From  all  this  it  was  evident  that  the  obstruction  was  at  the 
caecum  and  X-ray  examination  confirmed  this.  My  colleague, 
Mr.  Struthers,  saw  the  patient  and  opened  the  abdomen  on 
the  25th  September.  The  caecum  and  the  terminal  8  ins. 
of  the  ileum  were  removed  and  the  severed  ends  united. 
The  small  intestine  was  distended  and  hypertrophied.  The 
stricture  was  malignant.     The  patient  made  a  good  recovery. 

Stricture  at  Splenic  Flexure  :    C^cal  Perforation  : 
Double  Operation  :  Recovery 

Case  58. — Mrs.  M.,  aged  about  50,  was  seen  in  consultation 
with  a  doctor  now  deceased.  There  was  a  history  of 
recurring  attacks  of  obstruction  which  had  up  till  this 
time  been  overcome.  The  abdomen  was  much  distended. 
There  was  visible  peristalsis  in  the  lower  half,  the  movement 
passing  towards  the  caecal  region.  There  was  definite 
tenderness  in  this  region,  and  nowhere  else.  My  opinion 
was  that  there  was  malignant  stricture  at  the  caecum  and  that 
the  patient  ought  to  be  operated  on.  She  was  seen  a  week 
later,  operation  not  having  been  agreed  to.  The  abdomen 
was  more  distended  and  the  patient  stated  that  during  the 
previous  night  there  had  been  a  noise  hke  a  pistol-shot  in 
her  abdomen.  She  was  an  intelHgent  person  and  there 
was  no  reason  to  doubt  the  accuracy  of  her  statement.  In 
view  of  this  statement  it  seemed  clear  that  there  had  been 
a  perforation  at  the  caecum.  She  was  transferred  to  a 
nursing  home,  where  Professor  Caird  saw  her  and  opened  the 
abdomen.  The  transverse  colon  was  found  low  down  and 
distended  with  faeces,  which  excluded  the  possibihty  of  the 
caecum  being  the  seat  of  the  stricture.  It  was  found  to  be 
at  the  splenic  flexure.  The  peristalsis  which  had  been 
visible  was  evidently  produced  by  the  prolapsed  transverse 
colon.  When  the  caecum  was  investigated,  as  soon  as  it  was 
separated    from  the    parietes,  with  which  it  was  in  close 


222  THE   INTESTINAL   TRACT 

contact,  there  was  a  gush  of  liquid  faeces  from  a  caecal 
perforation.  The  perforation  was  secured  and  made  an 
outlet  for  the  contents  of  the  colon.  The  patient  did  remark- 
ably well  and  when  matters  had  become  stable  the  stricture 
at  the  splenic  flexure  was  removed  and  anastomosis  of  the 
colon  effected.  The  patient  made  a  complete  and  perfect 
recovery.  Professor  Caird  informs  me  that  the  caecum  is 
apt  to  give  way  in  cases  of  obstruction  at  the  splenic  flexure. 

Obstruction  at  Lower  End  of  Pelvic  Colon  :  Colostomy 

Case  59. — M.  S.,  aged  56,  was  admitted  to  hospital  on 
the  i6th  October.  In  the  previous  May  pain  began  in  the 
lower  part  of  the  abdomen  and  he  suffered  from  constipation. 
Action  of  the  bowels  was  obtained  by  means  of  small  doses 
of  cascara,  but  this  did  not  remove  the  pain.  The  pain 
was  described  as  coming  on  gradually,  increasing  until  it 
became  severe,  and  then  passing  off  gradually.  At  these 
times  there  might  be  a  call  to  go  to  stool,  but  only  a  httle 
blood  might  be  passed.  When  faeces  passed  they  were 
usually  formed  and  normal  in  colour.  The  symptoms  varied 
from  time  to  time  :  if  the  laxative  taken  did  not  act  the 
appetite  would  fail  and  he  might  become  actively  sick. 
The  abdomen  was  much  distended  and  tjonpanitic,  so  that 
on  examination  nothing  definite  could  be  made  out ;  there 
was  no  tenderness  ;  and  nothing  abnormal  was  felt  on  rectal 
examination.  X-ray  examination  showed  the  stricture 
to  be  at  the  lower  end  of  the  pelvic  colon.  He  was  transferred 
to  Professor  Caird's  ward  on  the  22nd  November,  and,  when 
the  abdomen  was  opened,  it  was  found  that  only  a  colostomy 
was  practicable.  This  patient  was  ultimately  removed  and 
died  some  time  later. 

Malignant  Disease  of  Rectum 
Malignant  disease  of  the  rectum,  while  it  may  affect  any 
part,  is  probably  more  common  in  the  upper  part  than  else- 
where. It  usually  gives  rise  to  pain  when  the  bowels  are 
moving  and  both  blood  and  mucus  may  be  passed.  There 
may  be   tenesmus  with   discharge  of   small   quantities   of 


MALIGNANT   DISEASE    OF   RECTUM         223 

mucus  and  blood  somewhat  frequently.  Such  symptoms, 
or  indeed  any  discomfort,  or  frequent  call  to  stool,  or  any 
unusual  complaint  referred  to  this  region  ought  at  once  to  be 
fully  and  carefully  investigated  both  outwardly  and  by  means 
of  a  finger  in  the  rectum.  The  possibiUty  of  early  malignant 
disease  should  never  be  lightly  set  aside.  When  present 
its  early  recognition  is  of  great  importance  and  calls  for 
surgical  interposition  without  undue  delay.  Without  such 
examination,  cases  are  labelled  "piles,"  "colitis,"  or  some 
equally  misleading  name,  and  their  true  nature  is  only 
recognized  when  radical  operation  cannot  be  attempted. 
Short  notes  of  a  few  cases  are  given  below  to  illustrate  the 
stage  at  which  they  are  sent  to  the  hospital  physician,  and 
show  how  grievous  the  results  are  of  misinterpreting  the 
bearing  of  symptoms  or  of  neglecting  to  make  a  rectal 
examination. 

Case  60. — James  M.,  aged  67,  was  admitted  on  the  30th 
October,  complaining  of  constipation  with  pain  in  the  region 
of  the  umbilicus.  He  attributed  his  condition  to  a  chill 
which  he  got  a  year  ago  which  affected  his  bowels.  Two  to 
three  months  later  constipation  became  more  marked  and 
for  days  he  would  pass  nothing  but  brownish-coloured  fluid. 
About  this  time,  he  began  to  have  recurring  attacks  of  abdo- 
minal pain.  When  pain  was  present  he  lost  appetite,  but 
when  he  got  the  bowels  properly  moved  appetite  returned, 
pain  disappeared,  and  he  felt  quite  well  until  the  same  series 
of  phenomena  returned.  These  attacks  had  kept  recurring 
up  till  the  time  of  admission.  There  was  no  vomiting.  In 
the  attack  shortly  before  admission  there  was  a  call  to  stool 
every  three  or  four  hours  and  he  only  passed  brownish- 
coloured  fluid.     He  noticed  that  he  was  getting  thinner. 

On  palpation  of  the  abdomen  nothing  could  be  made 
out,  but  examination  of  the  rectum  revealed  a  malignant 
mass  at  its  junction  with  the  sigmoid  flexure. 

Case  61. — C.  P.  was  brought  from  Cumberland  to  the 
Infirmary.  For  some  months  there  had  been  abdominal 
pain  with  constipation  and  the  passage  of  blood  and  mucus 
with  considerable   tenesmus.     Colitis  was   diagnosed.     On 


224  THE   INTESTINAL   TRACT 

deep  palpation  in  the  left  iUac  region  an  indefinite  lump 
could  be  just  reached.  On  examination  of  the  rectum  a 
nodulated  mass  was  felt  at  its  junction  \^dth  the  sigmoid 
flexure,  and  firmly  fixed.  Mr.  Wallace  saw  the  patient  and 
considered  the  condition  inoperable.  The  patient  was 
transferred  to  him  and  a  colotomy  gave  much  relief. 

Case  62. — Walter  H.,  aged  45,  was  admitted  on  the  22nd 
September  complaining  of  chronic  diarrhoea.  Diarrhoea 
began  about  nine  months  earHer.  There  would  be  as  man}^ 
as  eight  motions  a  da}-.  He  continued  at  work  until  two 
months  ago.  About  that  time  he  began  to  have  pain  in  the 
lower  part  of  the  abdomen.  It  came  on  about  half  an  hour 
after  every  meal,  and  was  relieved  when  the  bowels  moved. 
The  hea\der  the  meal  the  worse  the  pain.  Latterly  the 
motions  had  been  shmy  and  chocolate-coloured  He  often 
felt  sick,  but  never  vomited.  He  had  never  been  consti- 
pated. 'My  colleague  Mr.  Hodsdon  saw  this  patient  and 
kindly  took  him  in  charge,  but  decided  later  that  the  case 
was  inoperable,  removal  being  impracticable. 

Enterospasm 

The  name  indicates  the  nature  of  this  condition.  It  is 
an  interesting  and  important  affection,  not  common  and 
sometimes  very  difficult  of  diagnosis.  The  following  cases 
illustrate  it. 

Case  63. — Mrs.  W.,  aged  40.  This  patient  provides 
a  concrete  illustration  of  the  bearing  of  certain  principles 
which  underlie  and  determine  the  accuracy  of  abdominal 
diagnosis.  And  I  again  accentuate  the  proposition  that  we 
should  aim  at  accuracy  and  completeness. 

She  was  in  my  ward  recenth^  being  admitted  with  a 
history  of  severe  abdominal  pain  which  had  occurred  oftener 
than  once.  When  admitted  inspection  of  the  abdomen 
revealed  nothing  abnormal.  Palpation  revealed  no  swelling 
or  tenderness  ;  but  the  right  kidney  was  movable,  descending 
with  inspiration  and  slipping  up  with  expiration  :  it  was 
slightly  tender.  The  urine  showed  nothing  abnormal : 
and  all  the  other  organs  were  healthy.     The  patient  was  of 


ENTEROSPASM  225 

the  nervous,  highly-strung  type.  When  I  was  palpating  and 
speaking  of  the  mobihty  of  the  kidney  she  volunteered  the 
information  that  the  doctor  had  told  her  there  was  a  swelHng 
there  that  would  need  operation.  I  assumed  that  the 
swelling  meant  there  had  been  a  temporary  hydronephrosis 
due  to  the  mobility  of  the  organ.  I  accordingly  had  an 
abdominal  corset  made  for  her,  as  the  degree  of  mobility 
did  not  seem  to  me  to  justify  immediate  operation.  She 
went  home,  but  in  a  short  time  her  doctor  wrote  and  informed 
me  that  the  pain  had  returned,  so  she  was  re-admitted  to  the 
ward.  Her  condition  on  this  second  admission  was  quite 
different  to  what  it  had  been  during  her  former  stay  in  the 
ward.  Now  the  abdomen  was  projecting  and  distended, 
seemingl}^  from  distension  of  the  small  intestine,  and  there 
was  abdominal  pain  but  no  tenderness  at  the  caecum  or  else- 
where, and  there  was  nothing  abnormal  revealed  on  rectal 
examination.  The  colon  was  certainly  not  distended. 
There  was  no  sickness  and  the  bowels  were  relieved  by 
lavage. 

The  patient's  medical  attendant  kindly  came  into  town 
and  told  us  that  this  condition  had  recurred  from  time  to 
time  and  was  characterized  by  pain  and  similar  distension, 
and  that  there  had  not  been  hydronephrosis  as  she  had  led 
us  to  infer. 

The  condition  suggested  a  partial  block  at  the  ileo-csecal 
junction,  although  nothing  was  palpable  in  this  region.  The 
next  step  was  X-ray  examination,  and  this  was  carefully 
carried  out  by  Dr.  Hope  Fowler  in  the  electrical  department, 
but  no  point  of  blockage  was  shown.  The  only  other 
feasable  explanation  was  enterospasm,  and  the  abdomen  was 
examined  from  day  to  day.  The  pain  and  distension  varied 
from  day  to  day,  and  I  found  that  some  days  the  ascending 
colon  could  be  felt  strongly  contracted,  feeling  no  thicker 
than  one's  thumb,  while  other  days  it  would  be  two  or  three 
times  that  size.  This  strengthened  the  view  that  the 
symptoms  were  due  to  enterospasm  of  the  colon.  I  ordered 
belladonna  internally  and  gave  instructions  that  the  dose 
was  to  be  increased  until  the  physiological  effect  of  the  drug 

15 


226  THE   INTESTINAL  TRACT 

was  obtained.  There  was  no  marked  relief  and  the  possibility 
of  an  early  organic  lesion  at  the  ilio-caecal  junction,  not 
demonstrable  by  X-ray  examination,  obtruded  itself,  and 
my  surgical  colleague  who  kindly  saw  the  patient  thought 
the  abdomen  ought  to  be  opened,  as  he  thought  there  was 
an  organic  stricture.  The  abdomen  was  opened  and  no 
organic  stricture  or  lesion  of  any  kind  was  found. 

Remarks. — The  first  point  this  case  accentuates  is  the 
necessity'  of  accuracy  in  the  history  of  symptoms.  If  we 
had  seen  the  medical  attendant  earlier  we  would  not  have 
been  led  into  the  error  of  diagnosing  a  hydronephrosis 
because  there  was  a  movable  kidney  and  from  the  statement 
that  the  doctor  had  found  a  swelling  there.  In  the  second 
place,  the  case  is  an  added  illustration  of  what  becomes 
more  and  more  my  experience,  namely,  that  when  it  is  not 
quite  clear  that  there  is  something  definite  for  the  surgeon 
to  do  when  he  gets  inside  the  abdomen,  it  turns  out  that  there 
is  nothing  to  do.  In  this  particular  case  the  appendix  was 
removed  and  the  caecum  tacked  down ;  these  measures,  in 
conjunction  with  the  handling  necessary  for  full  examina- 
tion, were  likely  to  relieve  the  enterospasm  at  least  for  a 
time.  We  must,  however,  face  the  fact  that  the  abdomen 
ought  not  to  be  opened  for  the  relief  of  enterospasm  until 
it  is  quite  clear  that  all  possible  medical  measures  have  been 
exhausted. 

Case  64. — Miss  S.  The  preceding  case  recalls  the  case 
of  a  lady  sent  to  me  in  June,  1917.  She  suffered  from  an 
extreme  degree  of  constipation,  which  became  more  and 
more  difficult  to  overcome.  Some  years  previously  she  had 
been  operated  on  for  a  suppurating  appendicitis,  with 
extensive  peritonitis,  and  had  at  that  time  a  long  and  severe 
illness.  The  presumption  therefore  was  that  the  constipation 
was  due  to  adhesions.  On  examination  of  the  abdomen 
there  was  no  evidence  of  thickening  in  the  csecal  region  and 
the  ascending  and  transverse  colon  could  be  traced  as  far 
as  the  splenic  flexure,  and  it  was  of  good  size  ;  while,  from 
the  splenic  flexure  downwards,  the  colon  was  empty  and 
spastic.     The  question  was  whether  there  was  an  organic 


ENTEROSPASM  227 

stricture  at  this  point,  but  this  did  not  seem  to  be  probable 
as  the  constipation  had  lasted  for  years  and  there  had  never 
been  any  other  symptom  of  true  obstruction  beyond  the 
very  obstinate  constipation.  She  was  X-rayed  and  examined 
by  the  screen,  when  it  was  seen  that  the  bismuth  got  piled 
up  in  the  splenic  flexure,  while  below  it  the  colon  was  seen 
to  be  spastic  just  as  it  had  been  felt.  There  was  clearh' 
no  stricture  at  the  point  where  stricture  occurs.  I  suggested 
that  belladonna  should  be  given  in  as  large  doses  as  the 
patient  could  tolerate  and  I  had  the  satisfaction  of  hearing 
from  the  doctor  that  the  drug  had  "  acted  like  magic  "  and 
that  the  constipation  was  entirely  overcome. 


Section  TV.-THE   (ESOPHAGUS 
CHAPTER  XIX 

THE   (ESOPHAGUS 

(Esophageal  Obstruction. — ^This  is  the  only  condition  in  the 
oesophagus  requiring  consideration  here.  It  is  not  proposed 
to  deal  with  injuries  due  to  swallowing  hot  or  acrid  fluids, 
or  with  diverticula. 

It  might  be  thought  that  oesophageal  obstruction  gave 
rise  to  such  definite  symptoms  that  it  would  be  always 
diagnosed  at  an  early  stage,  and  yet  that  is  not  my  experience. 
So  far  as  the  ultimate  fate  of  the  patient  is  concerned,  the 
failure  to  recognize  its  beginning,  or  its  early  manifestation, 
does  not  carry  the  same  grave  responsibility  as  failure  to 
diagnose  an  early  cancer  of  the  stomach.  The  reason  for 
this  statement  will  presently  be  shown. 

Symptoms.  —  There  is  really  only  one  sjrmptom.  It 
consists  in  some  difficulty  in  swallowing  food.  It  is  not 
usually  a  pronounced  difficulty  at  first,  it  may  not  be 
constant,  and  it  may  have  been  noted  to  occur  only  with 
certain  kinds  of  food.  Whenever  such  a  complaint  is  made 
suspicion  ought  to  be  aroused,  and  careful  inquiries  made. 
The  patient  ought  to  be  seen  from  time  to  time  and  the 
symptom  asked  about.  The  first  complaint  may  be  that 
the  first  mouthful  is  felt  to  stick,  but  after  a  short  interval 
may  pass,  and  the  rest  of  the  meal  be  swallowed  without 
difficulty  ;  drinking  a  little  water  may  facihtate  the  passage 
of  the  stuck  portion.  In  some  cases  the  stuck  bit  may  be 
brought  up,  and  more  careful  mastication  or  taking  smaller 
pieces  of  food  into  the  mouth  prevents  further  difficulty  for 

228 


(ESOPHAGEAL   OBSTRUCTION  229 

the  time.  Very  commonly  the  first  article  of  food  which 
sticks  is  beef  or  mutton,  which  tends  to  be  swallowed  in  too 
large  pieces  and  imperfectly  masticated.  A  lump  of  potato 
may  also  stick  in  this  way.  These  symptoms  may  have 
continued  for  some  time  before  the  doctor  is  consulted.  In 
fact,  by  the  time  he  is  consulted  he  may  find  that  beef  and 
mutton  have  been  already  eliminated  from  the  dietary,  as 
they  could  not  be  swallowed,  or  because  "they  would  not  stay 
down."  At  this  stage  a  difficulty  arises,  for  the  patient  may 
state  that  beef  or  mutton  "  made  her  sick  ;  "  or  that  as  soon 
as  it  reached  the  stomach  she  vomited  it  just  as  it  had  been 
swallowed.  There  is  no  better  example  than  this  of  how 
a  doctor  may  be  misled  by  a  patient's  statements,  if  he 
accepts  them  at  their  medical  face  value.  He  has  to  get 
behind  his  patient's  use  of  the  words  "  sick  "  and  "  vomiting," 
for  they  are  not  used  in  the  medical  sense.  He  will  find 
that  the  stuck  piece  of  food  is  brought  up,  either  alone  or 
with  some  watery  mucus.  There  is  no  true  nausea  ;  there 
is  no  true  vomiting  ;  there  is  only  a  reversed  peristalsis  of 
the  oesophagus  accompanied,  perhaps,  by  a  diaphragm 
contraction.  After  beef  and  mutton  and  potatoes  have  been 
discarded,  fish,  fowl,  and  rabbit  follow.  Then  new  bread, 
toast,  and  indeed  bread  of  any  kind,  save  in  small  quantity 
and  very  carefully  masticated,  have  to  be  abandoned. 
Fluids  continue  to  pass  and  so  may  oatmeal  porridge  and 
farinaceous  puddings.  Later  the  porridge  and  the  puddings 
have  to  be  made  thinner.  Milk  and  beaten-up  eggs,  Benger's 
and  Allenbury's  foods,  and  meat  extracts  may  pass  easily,  if 
swallowed  slowly.  The  last  phase  is  when  fluid  nourishment 
even  in  small  quantity  passes  slowly  and  may  be  brought 
up.  During  all  this  time,  which  means  some  months, 
there  is  progressive  emaciation  and  advancing  cachexia. 

Etiology  and  Diagnosis. — Obstruction  of  the  oesophagus 
may  be  due  to  various  causes.  They  are  :  (i)  mediastinal 
neoplasm  or  aneurism  ;  (2)  spasm  ;  (3)  malignant  neoplasm 
in  the  tube  itself. 

With  regard  to  the  first  of  these,  obstruction  is  a  late 
phenomenon  ;    and  mediastinal  neoplasm  or  aneurism  has 


230  THE   (ESOPHAGUS 

usually  been  alread}'  diagnosed.  Spasm  occurs  most 
commonly  at  the  cardiac  opening ;  it  is  characterized  by 
not  being  constant ;  when  not  present  ordinary  food  can  be 
swallowed.  Persistently  recurring  spasm  suggests  the 
possibility  of  a  gastric  ulcer,  which  may  be  very  small, 
close  to  the  cardiac  opening.  \^'Tien  these  have  been 
excluded  there  remains  only  malignant  neoplasm  in  the  tube 
itself.  This  is  the  commonest  cause  of  obstruction,  so 
much  so  that  it  is  not  putting  the  matter  too  strongly 
to  say  that  a  constant  degree  of  obstruction,  although  some- 
times less  than  at  other  times,  has  to  be  proved  not  to  be 
malignant.  Clinically  and  pathologically  an  advancing 
obstruction  is  maUgnant,  when  mediastinal  pressure  has 
been  excluded.  If  aneurism  has  been  excluded  a  medium- 
sized  or  a  small  stomach  tube  may  be  used  to  explore  the 
oesophagus  and  to  judge  of  the  degree  of  organic  stenosis. 
Spasm  3delds  to  the  tube  usually.  Finally,  obstruction 
can  be  shown,  beyond  all  question,  to  be  present  by  radio- 
graphy. 

Treatment.  —  In  cases  of  cardiospasm,  belladonna  and 
valerian  may  be  helpful.  One  patient  with  recurring  spasm 
required  the  passage  of  the  tube  at  frequent  intervals.  In 
malignant  obstruction  there  is  little  that  can  be  done.  If 
there  is  evidence  of  spasm  belladonna  may  help.  So  long 
as  nutritive  fluids  pass  into  the  stomach  surgical  interposition 
is  not  to  be  advised.  All  that  the  surgeon  can  do  is  to  make 
a  stomach  opening  through  which  nourishment  can  be 
introduced. 

Case  65. — Miss  W.,  aged  51,  was  sent  from  the  North  of 
England  with  a  provisional  diagnosis  of  malignant  disease 
of  the  stomach.  The  symptoms  and  the  history  were 
clearly  those  of  oesophageal  obstruction.  The  main  point 
of  interest  in  the  history  was  that  the  earUest  manifestation 
of  food  sticking  was  hiccough.  Fig.  33,  the  radiogram  of  this 
case,  shows  the  oesophagus  in  its  lower  part  distended  and 
full  of  bismuth.  The  plate  from  which  this  figure  has  been 
produced  was  taken  by  Dr.  E.  Price.  This  case  is  used  as 
it  came  under  observation  when  this  was  being  written. 


R.Diaplira3i 


Fig.  33. — Case  65,  showing  dilated  oesophagus  filled  with  bismuth. 

[To  face  page  230. 


(ESOPHAGEAL  OBSTRUCTION  231 

No  useful  purpose  would  be  attained  by  loading  this  section 
with  a  record  of  cases.  They  are  monotonously  alike  when 
the  patient's  use  of  words  does  not  mislead  the  medical 
attendant.  The  skill  required  is  often  confined  to  the  power 
to  disentangle  and  interpret  aright  the  symptoms  as  described 
by  the  patient. 

The  following  case  is  added  as  pain  was  a  prominent 
symptom. 

Case  66. — Mr.  R.,  aged  68,  engineer,  was  seen  in  con- 
sultation. 

History. — Three  months  ago  he  began  to  suffer  from  pain 
in  the  back,  situated  in  the  upper  part  of  the  lumbar  region. 
He  had  lost  3  st.  in  weight,  since  the  beginning  of  his 
illness.  The  pain  was  constant,  it  was  not  intensified  by 
movement  of  the  trunk  in  any  direction.  About  the  same 
time  he  began  to  have  difficulty  and  pain  on  swallowing. 
He  described  the  pain  as  very  severe  until  he  brought  up 
"a  lot  of  sUme."  The  slime  came  up  when  he  attempted 
to  take  food,  after  taking  a  mouthful,  and  after  it  came  up 
he  could  swallow  his  food.  The  explanation  seemed  to  be 
that  spasm,  giving  rise  to  pain,  occurred  at  the  lower  end 
of  the  oesophagus,  and  that  as  a  result  mucus  and  saliva 
accumulated  above  this  ;  that  a  mouthful  of  food  determined 
a  reversed  peristaltic  movement,  which  led  to  the  ejection 
of  the  slime  ;  and  that  thereafter  the  bland  food  he  was 
taking  readily  passed  into  the  stomach.  Every  mouthful 
he  swallowed  caused  an  increase  in  the  ordinary  and  constant 
degree  of  pain,  and  this  intensification  persisted  for  fifteen 
to  twenty  minutes  after  he  had  finished  a  meal,  and  then 
subsided,  leaving  him  with  the  amount  which  was  constantly 
present  in  the  pit  of  the  stomach  and  in  the  back. 

On  examination  of  the  lumbar  region  no  tenderness  was 
eHcited  by  pressure,  and  no  pain  was  caused  by  movement 
of  the  spinal  column.  Examination  of  the  abdomen  anteriorly 
showed  marked  emaciation  with  hollowing.  There  was  no 
abnormal  projection  in  the  epigastrium,  and  on  palpation 
deeply  in  the  epigastrium  and  under  the  left  costal  margin 
no  swelHng  or  undue  resistance  was  present  and  no  pain 


232  THE   (ESOPHAGUS 

was  caused  by  the  pressure.  The  stomach  seemed  to  be 
small.  There  were  no  enlarged  glands  to  be  felt  in  the 
abdomen,  above  the  clavicles,  or  elsewhere  in  the  body. 
The  bowels  moved  regularly  ;  and  other  organs  presented 
nothing  abnormal  of  importance. 

Remarks. — ^The  symptoms  described  above  and  the  rapid 
loss  of  much  weight  led  inevitably  to  a  diagnosis  of  malignant 
stricture  at  the  lower  end  of  the  oesophagus.  The  only 
alternative  was  the  presence  of  an  aneurism  causing  spinal 
erosion  and  oesophageal  obstruction,  but  the  absence  of  all 
signs  of  erosion  seemed  to  exclude  definitely  this  as  a 
possibility  With  regard  to  treatment  pain  was  being  reheved, 
as  required,  by  belladonna  or  morphine.  The  patient  was 
able  to  swallow  milk,  porridge,  lightly  cooked  eggs,  soups, 
and  even  fish  and  toast  if  he  very  carefully  masticated  them. 
In  view  of  this  there  was,  of  course,  no  need  of  surgical  help. 


Section  V.— THE  LIVER 
CHAPTER   XX 

JAUNDICE    OR    ICTERUS 

Jaundice  or  icterus  is  the  name  given  to  the  discoloration 
of  the  tissues  following  upon  the  passage  into  the  blood  of 
the  bile  formed  by  the  liver.  The  skin  becomes  yellow  in 
colour  while  similar  and  early  colouring  of  the  conjunctivae 
also  appears.  The  urine  contains  bile,  the  presence  of  which 
can  be  demonstrated  by  the  ordinary  tests.  Jaundice  is 
not  a  disease  ;  it  is  a  symptom,  as  dropsy  is  a  symptom. 
It  always  means  that  there  is  obstruction  to  the  outflow  of 
bile  into  the  duodenum.  There  are  tintings  of  skin  and 
conjunctivae  sometimes  spoken  of  as  jaundice,  which  are 
not  true  jaundice.  Here  the  term  is  confined  to  the  colora- 
tion produced  by  secreted  bile  passing  into  the  circula- 
tion and  demonstrable  in  the  urine.  That  the  bile  is  not 
escaping  by  its  normal  outlet  into  the  duodenum  is  shown 
by  the  white  or  grey  colour  of  the  motions  and  by  their 
putty-like  or  clay-Hke  consistence.  The  determination  of 
the  cause  of  the  obstruction  in  the  individual  patient  is  the 
clinical  problem.  It  is  not  proposed  to  deal  with  jaun- 
dice met  with  in  certain  infective  maladies  and  poison- 
ings, but  to  limit  consideration  to  that  which  is  most 
commonly  seen  by  the  practitioner,  and  with  regard  to  which 
there  still  exist  diflfiiculties  and  hesitations,  in  the  hope  that 
differential  diagnosis  may  be  helped,  for  correct  diagnosis 
alone  can  indicate  the  line  of  rational  treatment.  It  is 
not  "  jaundice  "  which  has  to  be  treated  but  the  condition 
which  has  led  to  it.     The  immediate  cause  of  jaundice  in 

233 


234  THE    LIVER 

these  cases  is  purely  mechanical.  The  pressure  at  which 
bile  is  secreted  and  the  pressure  at  which  it  passes  into  and 
along  the  larger  bile  ducts  is  low,  so  that  a  relatively  small 
cause  may  completely  prevent  its  escape  into  the  duodenum. 
The  bile  which  has  been  produced  by  the  liver  ceUs  is  re- 
tained and  passes  by  way  of  the  lymphatics,  and  perhaps 
by  blood  capillaries  also,  into  the  blood.  As  a  consequence 
all  the  tissues,  organs,  and  fluids  of  the  body  are  stained  or 
coloured  by  it,  while  the  bowel  contents  are  wanting  in  bile 
colouring. 

The  conditions  which  lead  to  this  mechanical  obstruc- 
tion to  the  outpouring  of  bile  are  :  (i)  catarrh  of  the  second 
part  of  the  duodenum,  causing  swelling  of  the  mucous  mem- 
brane surrounding  the  orifice  of  the  common  duct  or  extend- 
ing a  short  distance  into  the  duct ;  (2)  calculus  in  the 
duct ;  (3)  inflammation  of  the  ducts  due  to  an  extension 
from  the  gall  bladder  or  consequent  upon  passing  of  a  stone  ; 
(4)  malignant  disease  of  the  head  of  the  pancreas  pressing 
upon  the  orifice  of  the  common  duct ;  (5)  new-growth  in  the 
liver  so  situated  as  to  press  upon  the  ducts  ;  (6)  new-growths 
outside  the  liver  so  situated  as  to  compress  the  ducts  ; 
(7)  new-growth  in  the  duodenum  so  situated  as  to  obstruct 
the  orifice  of  the  common  duct ;  (8)  animal  parasites  which 
directly  occlude  the  duct  or  by  their  presence  determine  a 
duodenal  catarrh  which  occludes  the  orifice  of  the  duct ; 
and  (9)  biliary  or  hypertrophic  cirrhosis  of  the  liver.  These 
causes  have  to  be  considered  in  detail,  for  the  treatment  and 
the  prognosis  are  determined  by  the  accuracy  of  the  differen- 
tial diagnosis  in  each  separate  case,  At  the  present  time, 
when  surgery  is  so  largely  dominated  by  the  newly  acquired 
sense  of  safety  in  operating  on  the  abdomen,  there  is  a 
tendency  on  the  part  of  many  practitioners  not  to  devote 
sufficient  attention  and  labour  to  the  acquisition  of  skill  in 
differential  diagnosis  ;  and  to  regard  all  cases  in  which  the 
differential  diagnosis  is  not  perfectly  simple  and  readily 
arrived  at  as  cases  in  which  exploratory  incision  is  unhesi- 
tatingly to  be  undertaken ;  the  extent  of  any  further  steps 
being  determined  by  the  diagnosis  made  with  the  abdomen 


JAUNDICE  235 

opened.  This  is  a  mental  attitude  and  a  practice  from  which 
there  is  aheady  a  certain  revulsion,  and  the  reaction  is  not 
only  inevitable,  but  its  acceleration  is  desirable.  The  per- 
forming of  unnecessary  laparotomy  is  as  reprehensible  as 
abstaining  from  operation  in  suitable  cases ;  and  the 
neglect  to  cultivate  the  skill  necessary  for  differential 
diagnosis  is  altogether  unworthy  of  any  branch  of  medicine, 
while  it  reduces  surgery  to  a  mere  expert  handicraft.  While 
holding  this  view  strongly,  one  recognises  that  there  are 
cases  in  which  it  may  be  impossible  to  differentiate  finally 
between  two  conditions,  and  in  which  it  is  right  to  give  the 
patient  the  chance  that  his  malady  may  be  the  less  of  two 
conditions.  Of  two  possible  conditions  it  not  infrequently 
happens  that  the  one  is  curable  b}^  surgical  means,  while 
the  other  is  quite  beyond  the  skill  of  surgery  to  influence. 
The  aim  of  the  physician  and  of  the  practitioner  assuredly 
is  to  reduce  to  a  minimum  the  number  of  laparotomies  which 
begin  with  the  abdominal  incision  and  end  with  its  immediate 
suturing.  This  can  only  be  reached  by  an  earnest  endeavour 
after  accuracy  in  diagnosis.  That  a  high  degree  of  accuracy 
is  attainable  cannot  be  questioned.  For  its  attainment 
there  are  three  lines  of  evidence  to  be  developed,  namely, 
first,  a  clear  and  accurate  account  of  the  history  of  the 
patient's  symptoms  ;  second,  a  skilful  examination  of  the 
abdomen  by  the  methods  in  general  use  ;  third,  a  correct 
knowledge  of  the  morbid  conditions  met  with  in  the  various 
viscera,  and  the  relation  of  viscera  or  parts  of  viscera  to 
the  abdominal  wall.  With  the  evidence  culled  from  these 
three  sources  the  accuracy  of  the  diagnosis  depends  upon 
the  measure  in  which  the  judgment  and  the  judicial  faculties 
have  been  cultivated  and  developed. 

The  conditions,  already  enumerated,  which  lead  to 
jaundice  may  now  be  considered  in  order. 

Catarrhal  Jaundice 

This  is  the  term  applied  to  jaundice  due  to  obstruction 
of  the  common  duct  by  catarrhal  swelling  of  the  mucous 
membrane   surrounding   its   orifice    or   invading   the   duct 


236  THE   LIVER 

itself.  A  duodenal  catarrh  is  therefore  always  present, 
and  is  indeed  the  essential  morbid  condition.  It  is  usually 
preceded  by  symptoms  of  gastric  disorder,  with  complaint 
of  "  indigestion  "  or  "  dyspepsia."  Discomfort  after  food, 
flatulent  distension,  gaseous  eructations  are  amongst  the 
common  symptoms.  A  furred  or  coated  tongue  indicates 
the  catarrhal  condition  of  the  stomach,  and  when  this 
extends  to  the  duodenum  jaundice  supervenes.  It  is  the 
commonest  form  of  jaundice.  In  children  and  in  young 
adults  it  is  the  usual  form,  but  it  is  not  rare  in  later  life. 
The  position  of  this  question  may  be  definitely  stated  to 
be  this,  namely,  that  in  the  first  half  of  life  the  presumption 
is  so  strongly  on  the  side  of  jaundice  being  catarrhal  that 
you  have  to  prove  that  it  is  not.  In  later  life  there  is  greater 
diihculty  than  in  earlier  life  in  determining  that  a  jaundice, 
which  has  come  on  without  much  previous  history  of  definite 
digestive  disturbance,  is  catarrhal,  and  not  due  to  early 
malignant  disease  of  the  head  of  the  pancreas,  or  to  a  primary 
cancer  affecting  the  duodenum  where  the  common  duct 
enters  it ;  this  latter  condition,  however,  is  very  rare.  As  a 
matter  of  fact  and  experience,  the  diagnosis  really  lies  between 
catarrh  and  malignant  head  of  pancreas. 

Treatment. — The  treatment  of  the  condition  is  the  treat- 
ment applicable  to  duodenal  catarrh.  The  diet  ought  to  con- 
sist of  skimmed  milk  and  farinaceous  foods.  Care  ought  to 
be  taken  to  have  the  food  very  thoroughly  mixed  with  the 
salivary  secretion  so  as  to  ensure  its  more  easy  digestion. 
Medicinal  treatment  consists  in  the  administration  of 
bicarbonate  of  soda,  rhubarb,  and  small  doses  of  salicylate 
of  soda.  A  small  dose  of  calomel  at  night,  followed  by  a 
small  dose  of  an  effervescing  saline  aperient  in  the  morning, 
may  be  given  for  a  few  days  in  succession,  or  on  alternate 
days.  It  is  better  so  to  regulate  the  dose  that  free 
movement  is  obtained  without  purging.  The  colour  of 
the  motions  shows  when  bile  has  begun  to  pass  into  the 
bowel,  and  as  soon  as  this  is  seen  the  diagnosis  of  catarrh 
may  be  regarded  as  confirmed.  If  the  condition  does  not 
speedily  yield  to  the  above  treatment  the  outlook  becomes 


JAUNDICE  237 

more  serious,  for  it  only  too  commonly  indicates  that  the 
cause  of  obstruction  is  beyond  either  medical  or  surgical 
skill. 

There  is  little  to  add  to  the  foregoing  beyond  empha- 
sizing certain  points.  Catarrh  occupies  the  first  place  in 
the  consideration  of  the  causation  of  jaundice.  The  cause 
of  the  stomach  catarrh  which  involves  the  duodenum  is 
commonly  some  error  in  diet.  I  have  seen  a  small  "  epi- 
demic "  of  catarrhal  jaundice  in  the  nurses  of  a  hospital ; 
but  the  error  in  the  individual  case  may  escape  detection, 
while  in  other  cases  the  patient  may  attribute  it  to  some 
article  of  food  which  had  produced  a  feehng  of  repulsion 
or  nausea  when  being  eaten.  The  icteric  tint  shows  first 
in  the  conjunctiva.  Bile  soon  appears  in  the  urine  and  the 
fseces  lose  their  bile  colouring.  The  duration  of  the  obstruc- 
tion varies  from  days  to  weeks,  and  there  is  only  one  test 
that  the  obstruction  has  been  removed  and  that  is  the 
reappearance  of  the  yellow  colour  of  the  faeces.  Imagined 
differences  in  the  colour  of  the  skin  and  urine  have  to  be 
put  aside  as  absolutely  unreUable  guides  as  to  the  patient's 
progress  ;  nothing  but  seeing  the  motions  day  by  day  is 
reliable.  After  the  motions  resume  the  normal  colour  bile 
rapidly  disappears  from  the  urine.  The  skin  coloration 
may  take  weeks  to  disappear  and  need  not  be  regarded 
seriously  from  the  medical  standpoint,  although  it  may 
offend  the  patient's  aesthetic  standards.  It  finally  disap- 
pears. 

\Vhile  the  disappearance  of  jaundice  as  a  result  of 
duodenal  catarrh  is  the  almost  universal  experience,  I  have 
seen  one  instance  in  a  woman  past  middle  life  in  whom  the 
jaundice  did  not  yield  to  any  treatment  directed  to  the 
duodenum.  The  persistence  and  intractability  of  the 
jaundice  led  to  the  opinion  that  it  was  due  to  malignancy  of 
the  head  of  the  pancreas.  The  patient  died  and  the  post- 
mortem examination  showed  the  lower  inch  or  less  of  the 
duct  blocked  with  tough  mucus.  This  possibility  has  to 
be  kept  in  mind  and  will  be  referred  to  again  under  jaundice 
due  to  malignant  disease  of  the  head  of  the  pancreas. 


238  THE  LIVER 

Obstruction   by  Calculus 

Calculi  are  commonly  formed  in  the  gall  bladder.  For 
obstruction  to  the  outflow  of  bile  to  be  caused  by  calculus  it 
is,  of  course,  necessary  that  the  calculus  should  be  present 
in  the  bile  duct  to  the  distal  side  of  the  point  at  which  the 
cystic  duct  opens ;  that  means  that  the  stone  has  passed 
along  the  cystic  duct  and  has  stuck  in  the  ductus  chole- 
dochus.     The  obstruction  leads  to  jaundice. 

Gall-stone  Colic — Gall-stone,  or  biliary,  or  hepatic  colic 
are  the  terms  applied  to  pain  caused  by  the  presence  of  gall- 
stone. The  stone  may  be  situated  in  the  gall-bladder  or 
the  larger  ducts.  When  in  the  gall-bladder  it  only  causes 
coKc  when  it  obstructs  the  mouth  of  the  cystic  duct.  Gall- 
stones are  found  on  post-mortem  examination  when  a  history 
of  gall-stone  cohc  is  awanting.  The  feature  of  all  colic  is 
its  sudden  onset,  and  its  sudden  subsidence ;  and  the 
appellation  is  confined  to  the  abdominal  viscera.  The 
passage  of  a  gall-stone  along  the  cystic  duct  or  the  ductus 
choledochus  always  causes  pain.  The  degree  of  pain 
depends  mainly  upon  the  size  of  the  stone.  The  pain  may 
be  agonizing ;  it  may  be  so  intense  as  to  kill  if  relief  is  not 
speedily  afforded.  If  the  stone  or  stones  are  small  they 
may  pass  with  so  little  discomfort  that  their  existence  maj?^ 
not  even  be  thought  of.  When  a  stone  sticks  and  causes 
jaundice  it  is  of  larger  size  and  yet  not  so  large  that  it 
failed  to  pass  the  cystic  and  enter  the  common  duct.  The 
pain  is  usually  sudden  in  onset,  and  may  immediately 
attain  intense  severity.  It  is  referred  to  the  abdomen, 
either  all  over  it,  or  mainly  to  the  umbilical,  epigastric,  or 
right  hypochondriac  region.  In  severe  cases  there  may  be 
diffuse  abdominal  tenderness,  which  can  easily  be  mis- 
construed, and  be  regarded  as  a  sign  of  general  peritonitis. 
It  is  in  reality  a  surface  hyperaesthesia,  and  has  to  be  dis- 
tinguished from  the  corresponding  condition  in  perforation. 
When  jaundice  is  due  to  gall-stone  there  is  always  a  definite 
history  of  one  or  more  severe  attacks  of  pain  such  as  has 
been  indicated.     The  jaundice  may  follow  upon  the  first. 


JAUNDICE         .  239 

which  may  also  have  been  the  only  attack  of  pain  ;  but  there 
may  be  a  history  of  many  attacks,  which  have  not  been 
followed  by  jaundice,  and  which  have  passed  without  their 
true  nature  ha\'ing  been  recognized.  This  history  of 
paroxysmal  pain,  or  colic,  is  the  key  to  the  diagnosis  when 
jaundice  appears.  Whatever  difhculty  there  may  be  in  the 
early  stage  of  a  case  of  abdominal  pain  the  onset  of  jaundice 
commonly  sets  the  question  of  diagnosis  at  rest.  The 
differentiation  of  biliary  from  other  forms  of  colic  presents, 
not  infrequently,  considerable  difficulty.  Care  has  to  be 
taken  when  the  history  of  pain  is  being  investigated  that 
the  essential  points  are  clearly  and  unequivocally  determined  ; 
these  are  the  mode  of  onset,  whether  gradual  or  sudden  or 
steadily  developing  in  severity  ;  the  intensity  of  the  pain  ; 
and  the  site  to  which  it  is  referred.  Vague  general  questions 
and  answers  are  of  no  value  in  this  inquiry,  and  it  may  require 
patience  and  considerable  tact  to  get  the  patient  to  answer 
questions  with  approximate  accuracy.  The  pain  of  gall- 
stone colic  has  no  constant  relation  to  taking  food,  it  is 
erratic  in  its  manifestations,  usually  sudden  in  its  onset, 
and  as  sudden  in  its  cessation.  Although  having  no  constant 
relation  to  taking  food,  it  may  be  noted  that  attacks  may  be 
determined  by  large  meals. 

The  diagnosis  that  colic  is  hepatic  in  origin  is  simplified 
by  recalling  and  restating  the  causes  which  lead  to  the 
sudden  onset  of  pain  in  the  abdomen  ;  they  are  constipation, 
intestinal  obstruction,  hernia,  internal  or  external,  gastric 
or  intestinal  perforation,  renal  colic,  and  hepatic  or  gall-stone 
colic.  This  may  be  further  simplified  by  stating  that  the 
seat  of  pain  is  in  the  gastro-intestinal  tract,  in  the  kidney, 
or  in  the  hver.  In  the  stomach  acute  severe  pain  may  be 
due  to  perforation  ;  but  in  perforation  with  considerable 
escape  of  gastric  contents  into  the  peritoneal  cavity  there  is 
a  degree  of  collapse  not  met  with  in  hepatic  or  renal  colic, 
and  the  same  is  true  of  duodenal  perforation.  In  the  rest 
of  the  intestinal  tract  primary  ulceration  with  perforation 
may  be  excluded.  Intestinal  obstruction  from  malignant 
stricture  occurs  practically  only  in  the  colon  and  is  preceded 


240  THE  LIVER 

by  a  history  of  constipation,  more  and  more  difficult  to 
overcome,  while  obstruction  with  pain  and  vomiting  does 
not  set  in  precipitately.  The  seat  of  obstruction  can 
often  be  determined  by  physical  examination.  Internal 
hernia  gives  rise  to  pain  referred  to  the  site  of  obstruction 
and  the  pain  leads  to  vomiting.  In  renal  colic  pain  is 
mainly  lumbar,  although  in  less  degree  it  may  be  felt  anter- 
iorly ;  on  careful  bimanual  palpation  the  true  seat  of 
tenderness  is  found  to  be  the  renal  region.  In  hepatic 
colic  the  pain  is  referred  to  the  right  hypochondrium  as  its 
seat  of  origin,  and  by  palpation  the  true  seat  of  tenderness 
is  over  the  liver  edge.  The  determination  of  the  true  seat 
of  tenderness  has  in  all  cases  to  be  slowly  and  critically 
determined  when  the  surface  hyperaesthesia  has  been  over- 
come. This  can  usually  be  effected  by  gentle  friction 
with  the  hand  and  by  gradually  making  iirmer  palpation. 
If  duodenal  perforation  and  kidney  are  excluded,  and  they 
usually  can  be  excluded,  there  is  no  alternative  to  the 
diagnosis  of  hepatic  colic.  The  idea  that  hepatic  colic 
is  not  to  be  diagnosed  until  jaundice  appears  is  deplorably 
wrong.  There  is,  however,  a  question  in  some  cases  of 
diagnosis  between  chronic  duodenal  ulcer  and  gall-stone. 
In  duodenal  ulcer  pain  has  a  definite  relation  in  time  to  the 
preceding  meal,  a  relation  which  tends  to  repeat  itself  ;  but 
pain  is  not  necessarily  present  after  every  meal.  It  is 
influenced  by  the  character  of  the  meal  which  has  been 
taken.  Recurring  hepatic  colic  on  the  other  hand  is  more 
eratic  in  its  manifestations,  sometimes  appearing  to  have 
been  determined  by  the  preceding  meal,  but  paroxysms 
occurring  apart  from  such  relationship. 

Passing  of  Small  Stones. — Gall-stone  colic  must  always 
be  considered  from  the  standpoint  that  gall-stones  are  often 
of  small  size,  that  one  or  many  such  stones  may  pass  into 
the  duodenum  and  give  rise  to  pain  when  passing.  The 
not  uncommon  idea  that  a  colic  was  not  hepatic  because  it 
passed  off  without  causing  jaundice  has  to  be  definitely 
abandoned  both  in  practice  and  in  teaching.  It  has  been  a 
barrier  to  the  recognition  of  many  cases  in  which  there  would 


JAUNDICE  241 

have  been  no  difficulty  in  diagnosis  but  for  its  existence. 
Many  cases  are  seen  in  which  there  has  been  a  single 
attack  of  such  colic  ;  or  several  attacks  with  intervals  of 
years  of  complete  freedom.  It  cannot  therefore  be  assumed 
that  an  attack  wiU  not  subside.  The  stone  may  pass, 
but  even  if  it  remains  in  the  gall-bladder  it  may  cease  for 
long  periods  to  cause  pain.  If  a  stone  has  been  passed, 
another  may  form  at  a  later  date,  again  cause  pain,  and 
again  be  passed.  These  are  foundation  facts  which  ought 
to  influence  our  judgment  in  individual  cases.  They  are 
so  fundamental  that  the  position  comes  to  be  this,  that  it 
has  to  be  shown  in  the  individual  case  that  the  stone  is  not 
to  pass  without  undue  suffering  and  risk. 

Treatment. — If  the  diagnosis  of  impacted  gall-stone  is 
made,  the  expectant  line  of  treatment  may  be  adopted  for  a 
limited  time,  in  the  hope  that  the  stone  may  pass.  The 
bowels  ought  to  be  Icept  moving  easily,  and  belladonna  be 
given  with  a  view  to  relaxing  spasm.  If  these  measures 
are  not  followed  by  rehef,  or  if  the  patient  continues  to  suffer 
from  recurring  attacks  of  colic,  the  only  remedy  is  the 
surgeon's  knife. 

Cholangitis,  or  Inflammation  of  the  Bile  Ducts 

Inflammation  of  the  bile  ducts  leads  to  jaundice  by  the 
blockage  of  the  ducts  with  inflammatory  products.  While 
inflammation  may  occasionally  be  an  extension  from  a 
primary  duodenal  inflammation,  on  the  one  side,  or  of  a 
primary  inflammation  of  the  gall-bladder  on  the  other, 
it  is  more  commonly  set  up  by  calculus.  The  calculus  may 
have  been  arrested  in  transit  from  the  gall-bladder,  or  it 
may  have  passed,  but  in  its  passage  have  so  injured  the 
duct  that  inflammation  followed  its  passage.  In  other 
cases  there  may  be  one  or  a  number  of  calculi  in  the  gall- 
bladder, which  indicate  their  presence  by  attacks  of  pain 
consequent  upon  one  of  them  becoming  engaged  in  the 
mouth  of  the  cystic  duct.  During  such  an  attack  of  cohc, 
which  may  be  very  severe,  a  cholecystitis  may  be  set  up, 
with    the    inflammation  extending  rapidly    to    the    ducts, 

16 


242  THE  LIVER 

leading  to  their  blockage  and  to  jaundice.  In  such  cases 
there  is  a  like  history  of  paroxysmal  pain  as  was  referred  to 
in  the  previous  sub- section ;  but  along  with  pain  there  is  a 
rise  of  temperature,  of  the  septic  type.  There  may  even  be 
slight  rigors  with  sweating ;  and  examination  of  the  blood 
shows  a  polymorphonuclear  leucocytosis.  The  diagnosis 
in  cases  of  this  kind  is  simple  as  soon  as  the  jaundice  appears  ; 
any  difficulty  is  in  the  pre- jaundice  stage,  when  severe  pain 
and  elevated  temperature  are  the  leading  and  indeed  only 
prominent  symptoms.  The  combination  of  these  symptoms 
is,  however,  pathognomonic  of  cholecystitis  or  cholangitis, 
or  both  combined,  associated  with  calculus.  The  severity  of 
the  S3niiptoms  in  this  class  of  case  varies  very  greatly  and 
can  be  best  illustrated  by  brief  reference  to  typical  cases. 

Case  67. — Male,  aged  65,  had  one  or  two  attacks  of  colic 
which  at  the  time  of  their  occurrence  had  not  been  recog- 
nized as  of  bihary  origin.  Some  time  afterwards  fever 
supervened  and  jaundice  made  its  appearance.  This  state 
of  affairs  was  allowed  to  continue  for  some  weeks,  but  finally 
operation  was  agreed  to.  No  calculus  was  found,  but  the 
gall-bladder  and  bile  ducts  were  inflamed.  The  gall-bladder 
was  drained  and  the  patient  made  a  good  although  a  slow 
recovery. 

Case  68. — Female,  in  middle  life,  was  deeply  jaundiced, 
emaciated,  and  exhausted  when  she  came  into  my  hands  in 
hospital.  She  had  a  septic  temperature  with  occasional 
slight  rigors.  The  history  indicated  that  there  had  been 
attacks  of  coUc  early  in  the  course  of  the  illness.  In  view 
of  this  and  of  the  fact  that  she  was  steadity  losing  ground, 
I  strongly  advised  her  to  submit  to  operation.  This  she 
consented  to,  and  Mr.  Hodsdon,  one  of  my  surgical  colleagues, 
performed  the  operation.  No  stone  was  found,  but  the  gall- 
bladder was  drained,  with  the  result  that  the  patient  at  once 
began  to  improve  ;  the  jaundice  disappeared,  she  began  to 
take  food  readily,  put  on  flesh,  and  in  a  few  weeks  was  able 
to  be  out  of  bed. 

Remarks.— In  these  two  cases  there  was  definite  history 
of  gall-stone  colic  before  jaundice  had  appeared.     Along 


JAUNDICE  243 

with  the  onset  of  jaundice  there  was  rise  of  temperature. 
The  rise  of  temperature  indicated  an  inflammatory  cause  for 
the  jaundice,  and  this  having  been  preceded  by  attacks  of 
pain  pointed  to  calculus  as  setting  up  the  inflammation. 
The  subsidence  or  disappearance  of  pain  indicated  either 
that  the  calculus  had  passed  or  that  it  was  still  in  the 
gall-bladder  although  not  so  placed  as  to  cause  pain.  It 
must  be  remembered  that  the  passage  of  a  stone  does  not 
necessarily  cause  cholangitis  and  jaundice.  On  the  other 
hand,  jaundice  due  to  cholangitis,  following  upon  gall-stone 
colic,  if  persistent,  demands  surgical  interposition,  yet  a 
stone  may  not  be  found  when  the  parts  are  examined.  If 
there  has  been  an  absence  of  colic  for  some  time,  notwith- 
standing the  persistence  of  jaundice,  the  presumption  is 
that  no  stone  will  be  found,  but  none  the  less  the  gall-bladder 
ought  to  be  opened  and  drained,  for  it  is  the  only  effective 
method  of  dealing  with  the  cholangitis. 

Cholecystitis  and  Cholangitis  due  to  Gall-bladder  Calculi. — 
It  has  been  already  stated  that  the  presence  of  calculi  in 
the  gall-bladder  does  not  necessarily  lead  to  attacks  of  colic. 
On  the  other  hand,  however,  there  may  be  many  and  severe 
attacks  without  jaundice.  In  some  cases  jaundice  appears 
after  one  or  other  attack  and  when  it  does  so  it  is  commonly 
associated  with  a  rise  of  temperature.  In  cases  of  this 
kind  it  is  found  that  cholecystitis  has  supervened,  and 
that  the  inflammation  has  rapidly  extended  to  the  ducts, 
leading  to  partial  or  complete  obstruction  of  them.  The 
facts  are,  whatever  explanation  may  be  advanced  regarding 
them,  that  stone  or  stones  may  be  long  present  and  cause 
severe  attacks  of  colic  without  causing  cholecystitis,  while 
in  some  one  attack  cholecystitis  may  supervene  with  inflam- 
mation spreading  rapidly  to  the  ducts.  Without  extension 
to  the  ducts  jaundice  does  not  develop.  The  following 
case  illustrates  several  of  the  points  referred  to  and  speciall}/ 
the  fact  that  stones  may  exist  without  causing  severe 
pain;  that  a  time  comes  when  a  mild  cholec5/stitis  and 
angitis  may  supervene  with  jaundice,  that  this  may  subside 
but  be  followed  by  still  more  severe  attacks  of  colic,  and  yet 


244  THE  LIVER 

all  the  time  the  stones  may  be  present  and  confined  to  the 
gall-bladder. 

Case  69. — A  lady,  aged  65,  had  for  years  suffered  from 
attacks  of  abdominal  pain  with  a  little  rise  of  temperature, 
which  she  thought  were  threatenings  of  a  recurrence  of  an 
appendicitis  from  which  she  had  suffered  many  years 
before.  A  day  or  two  in  bed  and  a  dose  of  castor  oil  with 
laudanum  was  followed  by  recovery.  Quite  suddenly  one 
day  she  was  seized  with  very  severe  abdominal  pain  which 
was  only  restrained  by  the  subcutaneous  administration  of 
considerable  doses  of  morphine.  She  had  several  such 
attacks  of  pain  and  the  temperature  rose  somewhat.  "When  I 
saw  her  that  was  her  condition,  but  in  addition  there  was 
tenderness  over  the  gall-bladder.  There  seemed  to  me  to  be 
no  doubt  as  to  the  cause  of  the  symptoms  and  the  onset  of 
jaundice  fully  confirmed  my  view.  After  full  considera- 
tion, it  was  decided  to  postpone  the  question  of  operation. 
In  the  course  of  six  weeks  the  temperature  became  normal, 
the  jaundice  disappeared,  and  the  patient  was  able  to  move 
about.  Not  long  afterwards  there  was  another  attack  of 
very  severe  pain,  which  was  again  made  bearable  only 
by  deep  chloroform  narcosis  followed  by  morphine.  The 
temperature  again  rose,  the  region  of  the  gall-bladder 
became  tender  and  slight  jaundice  supervened.  1  strongly 
recommended  operation  on  the  ground  that  stones  were 
present,  which  were  not  escaping  into  the  intestine,  but 
which  when  they  got  into  the  mouth  of  the  duct  caused 
pain  followed  by  cystitis  and  cholangitis.  She  was  operated 
upon  by  Mr.  Cotterill  and  Mr.  Hodsdon,  and  eight  good- 
sized  stones  were  removed  from  the  gall-bladder.  No  stone 
was  found  in  the  ducts,  but  notwithstanding  that  the  gall- 
bladder was  drained.  Complete  recovery  followed,  and  the 
lady  enjoyed  a  degree  of  comfort,  and  a  measure  of  strength 
and  vigour,  which  she  had  not  experienced  for  years. 
There  was  also  no  return  of  the  attacks  which  were 
previously  reierred  to  the  appendix. 

Treatment. — In  what  has  been  already  said  the  treatment 
is  indicated.     If  calculus  with  cholecystitis  or  cholangitis 


JAUNDICE  245 

is  diagnosed,  time  ought  to  be  allowed  to  give  the  stone  a 
chance  of  passing  and  the  inflammation  an  opportunity  to 
subside.  These  may  be  facilitated  by  giving  the  patient 
a  course  of  belladonna  internally  and  applying  belladonna 
with  hot  fomentations  or  poultices  locally.  The  bowels 
ought  also  to  be  carefully  seen  to,  and  the  diet  ought  to  be  of 
the  lightest  description. 

Malignant  Disease  of  the  Head  of  the  Pancreas 

Mahgnant  disease  of  the  head  of  the  pancreas  causes 
jaundice  by  pressing  upon  and  thus  obstructing  the  opening 
into  the  duodenum  of  the  portion  of  duct  common  to  the 
pancreatic  and  biliary  secretions.  This  affection  of  the  pan- 
creas leads  early  to  obstruction.  It  commonly  occurs  after 
middle  life,  being  by  no  means  common  in  the  first  four  decades 
of  hfe.  When  the  disease  in  the  pancreas  is  secondary  to 
cancer  of  the  pyloric  end  of  the  stomach  the  pyloric  condition 
has  usually  declared  itself  before  jaundice  appears,  so  that  this 
further  development  is  regarded  merely  as  a  step  in  the  down- 
ward course  of  the  patient.  The  same  may  be  true  of  pancreas 
involvement  from  other  primary  sites.  When,  however, 
the  pancreas  is  the  primary  site  of  the  disease  jaundice  is 
commonly  the  first  symptom  which  attracts  notice  or  receives 
serious  consideration.  Primary  cancer  of  the  head  of  the 
pancreas  is  not  rare.  Indeed,  it  is  sufficiently  common  to 
raise  the  question  in  all  cases  which  have  not  been  preceded 
by  any  definite  history  of  digestive  disorder,  whether  it  is  not 
the  cause  of  an  existing  jaundice.  The  absence  of  evidence  of 
gastric  or  duodenal  catarrh  considerably  deepens  the  suspicion 
that  Hes  upon  the  pancreas  in  this  kind  of  case.  A  further 
deepening  of  the  suspicion  is  induced  by  the  experience  that, 
in  spite  of  measures  directed  to  the  removal  of  any  duodenal 
catarrh  which  might  have  been  present,  the  jaundice  does 
not  lessen  but,  on  the  contrary,  becomes  more  intense. 
The  failure  to  obtain  improvement  in  spite  of  msely  admini- 
stered therapeutic  measures  becomes  in  itself  a  point  of  much 
diagnostic  significance.     In  fact,  the  persistence  of  jaundice 


246  THE  LIVER 

for  some  weeks,  in  spite  of  treatment,  without  a  history 
suggesting  calculus,  and  wanting  in  unequivocal  signs  of 
tumour,  may  quite  reasonably  be  attributed  to  the  pancreas. 
Signs  of  tumour  may  not,  however  be  so  entirely  absent. 
If  skill  has  been  acquired  in  the  palpation  of  the  abdomen, 
the  hardened  and  somewhat  enlarged  head  of  the  pancreas 
may  be  felt  in  its  normal  position.  'V^'lien  it  can  be  so  felt 
it  is  in  my  experience  definitely  tender  when  moderate 
pressure  is  made  upon  it.  Palpation  is  facilitated  as  the 
case  goes  on  by  the  progressing  emaciation  of  the  patient, 
and  perhaps  by  the  head  enlarging.  The  head,  however, 
does  not  attain  any  striking  enlargement,  so  a  great  tumour 
mass  must  not  be  expected.  Other  points  are  regarded  as 
assisting  in  the  differential  diagnosis,  such  as  an  excess  of  fat 
in  the  stools,  from  the  absence  of  the  pancreatic  secretion  ; 
but  all  causes  which  lead  to  obstruction  of  the  common  duct, 
be  it  calculus  or  catarrh  or  malignant  disease,  rob  the 
food  of  the  benefit  of  the  pancreatic  secretion  with  its  several 
important  and  essential  enzymes.  Efforts  have  been  made 
by  chemical  analysis  of  the  urine  to  determine  the  question 
of  the  involvement  or  freedom  of  the  pancreas  from  mahgnant 
disease,  but  this  method  of  investigation  has  not  so  far  given 
data  which  seem  to  be  rehable.  The  diagnosis  may  be 
regarded  as  practically  dependent  upon  the  considerations 
which  have  been  dealt  with  in  the  first  part  of  this  section. 

Treatment. — ^This  condition  presents  only  one  question 
for  consideration  and  that  is  whether  we  are  to  recommend 
operation  to  give  an  artificial  outlet  to  the  bile.  The  misery 
sometimes  experienced  from  the  distressing  itchiness  of  the 
skin  seems  to  warrant  the  serious  consideration  of  this 
question.  \Vhether  the  mental  sjrmptoms  caused  by  the 
chol^mia  ever  warrant  it  is  a  consideration  to  be  set  against 
the  mode  of  death  after  effective  and  continuous  drainage 
has  been  secured.  I  have  dehberately  advised  that  the 
gall-bladder  be  opened  in  the  former  class  with  a  view  to 
drainage  for  the  rehef  of  the  itchiness,  and  the  restless 
irritability  the  patients  experienced.  In  some  cases  the 
operation   was   delayed   too   long   owing   to   the   patients 


JAUNDICE  247 

declining  at  first  to  risk  an  operation  which  they  were 
informed  would  at  the  best  be  only  palliative.  Ultimately 
their  discomfort  became  so  great  that  they  desired  to  have 
the  operation  performed.  Another  patient  was  operated  on 
at  my  suggestion  in  the  hope  that  the  cause  of  the  jaundice 
was  removable,  but  at  the  operation  it  was  found  to  be  due 
to  malignant  disease.  The  gall-bladder  was,  however, 
attached  to  the  surface  incision  so  as  to  allow  free  external 
drainage  for  the  bile.  She  made  an  excellent  recovery  from 
the  operation,  the  jaundice  cleared  away,  and  she  was 
delivered  from  the  distressing  itchiness  and  general  sense  of 
discomfort  she  had  experienced  from  the  jaundice.  A  case 
of  the  second  type  was  a  woman,  aged  55,  who  was  admitted 
to  my  ward  on  27th  September,  191 8,  suffering  from 
jaundice  which  had  lasted  for  three  to  four  months.  The 
duration  practically  negatived  its  being  due  to  duodenal 
catarrh.  There  was  no  history  of  gall-stone  cohc.  There 
was  no  elevation  of  temperature,  so  cholecystitis  and  cho- 
langitis were  excluded.  The  head  of  the  pancreas  was  felt 
indefinitely  and  it  was  tender.  There  was  thus  no  reasonable 
escape  from  a  diagnosis  of  cancer  of  the  head  of  that  organ 
pressing  upon  the  common  duct.  The  patient  very  much 
resented  the  soporific  and  apathetic  state  into  which  she  was 
slowly  but  definitely  slipping  ;  she  was  anxious  to  be  reheved 
and  quite  wilUng  to  be  operated  on.  She  was  transferred 
to  my  colleague,  Mr.  Miles,  on  the  19th  October,  and  the 
abdomen  was  opened  on  the  22nd ;  the  diagnosis  was 
confirmed,  and  an  opening  established  between  the  gall- 
bladder and  the  small  intestine.  She  made  an  excellent 
recovery,  and  was  re-admitted  to  my  ward  on  the  4th 
November.  She  was  entirely  relieved  from  the  cholaemic 
symptoms,  was  greatly  pleased  with  the  result  of  the  opera- 
tion, and  returned  home  on  the  12th  November. 

The  following  is  the  record  of  the  fiist  patient  who  was 
operated  on  for  jaundice  due  to  cancer  of  the  head  of  the 
pancreas  at  my  instigation.  The  case  was  presented  and 
discussed  at  the  Edinburgh  Medico-Chirurgical  Society,  and 
the  following  is  reproduced  from  the  Society's  Transactions. 


248  THE   LIVER 

"Mrs.  L.  was  admitted  to  Queensberry  House  Hospital, 
as  she  had  sustained  an  intracapsular  fracture  of  the  femur 
which  rendered  her  incapable  of  attending  to  herself  in  her 
o^^^l  house,  as  she  had  hitherto  done.  Her  age  on  admission 
was  85,  and  no  measures  by  means  of  sphnts  or  extension 
were  taken  with  a  view  to  bring  about  union  of  the  broken 
bone.  In  the  course  of  some  weeks  she  was  lifted  out  of  bed 
to  an  easy  chair  for  several  hours  almost  daily,  this  being 
beneficial  to  the  general  health  and  a  preventive  of  back 
irritation  and  bed-sores.  Such  was  the  life  the  patient 
was  leading  in  the  early  part  of  the  year.  She  was  rather  a 
short,  plump  woman,  with  a  very  contented  and  well- 
balanced  mind,  not  looking  her  age  by  fully  fifteen  years, 
and  with  all  her  faculties  intact  and  on  the  alert.  Her 
arteries  were  httle  thickened ;  in  fact,  they  gave  as  httle 
indication  of  her  age  as  her  general  appearance  and  mental 
faculties  did.  In  April  she  suffered  from  shght  dyspeptic 
S5niiptoms,  which  were  not  thought  much  of  until  she  began 
to  show  a  suspicion  of  jaundice,  confirmed  by  finding  bile 
in  the  urine.  The  most  careful  physical  examination  of 
the  abdomen  at  this  time  revealed  nothing  abnormal,  and 
I  hoped  the  bihary  obstruction  was  due  to  duodenal  catarrh. 
This  is  the  hope  to  which  I  usually  give  my  adhesion  in 
such  cases,  although,  as  a  matter  of  experience,  I  have  not 
found  that  jaundice  from  duodenal  catarrh  is  usual  in  persons 
over  middle  hfe.  My  experience  has  rather  been  that  the 
hope  with  which  I  first  regard  these  cases  has  had  to  give 
way  before  the  development  of  evidence  which  puts  the 
diagnosis  quite  beyond  the  pale  of  doubt  and  of  hope.  In 
young  persons,  and  in  younger  adult  life,  on  the  other  hand, 
a  diagnosis  of  catarrhal  obstruction  which  has  been  carefuUy 
made  is  usually  correct.  It  soon  became  apparent  that  the 
obstruction  in  this  case  was  not  to  yield  to  the  remedies 
which  are  early  successful  when  the  cause  is  a  duodenal 
catarrh,  and  I  watched  very  carefully  for  the  first  evidence 
that  might  present  itself  which  would  throw  distinct  Hght 
upon  the  cause  of  the  obstruction.  My  attention  was 
necessarily  most  closely  directed  to  the  region  of  the  pancreas. 


JAUNDICE  249 

from  the  presumption  that  the  cause  would  probably  turn 
out  to  be  situated  there.  From  time  to  time  I  therefore 
carefully  explored  the  abdomen  in  that  region,  and  the 
signs  noted  were  the  following  : — The  pulsation  of  the 
abdominal  aorta  was,  of  course,  evident  and  marked,  but  I 
early  noted  that  the  pulsation  appeared  to  become  more 
marked  to  palpation,  as  if  the  vessel  had  become  larger  at 
that  part,  or  as  if  there  were  something  between  the  hand 
and  the  vessel,  and  overlying  it,  and  to  which  the  pulsation 
was  communicated.  This  after  a  time  could  be  fairly 
satisfactorily  resolved  into  an  elongated  structure  mth  a 
somewhat  firm  or  tough  sense  of  resistance,  which  from  its 
position  and  shape  was  beUeved  to  be  the  pancreas.  The 
normal  pancreas  cannot,  as  a  rule,  be  felt  with  any  measure 
of  certainty,  but  when  its  consistence  becomes  increased 
and  its  tissue  hardened,  it  can  be  felt  if  the  abdominal 
parietes  are  not  too  tense  or  the  abdominal  wall  not  too  laden 
with  fat.  While  the  pancreas  became  thus  palpable,  the 
absence  of  any  palpable  thickening  above  or  to  its  right 
made  it  improbable  that  either  the  pyloric  outlet  of  the 
stomach  or  the  duodenum  was  the  seat  of  material  lesion. 
That  the  pylorus  was  not  affected  was  further  rendered 
probable  by  the  absence  of  gastric  dilatation,  or  any  e\ddence 
of  marked  derangement  of  gastric  function.  As  time  passed, 
the  right  extremity  of  what  was  beUeved  to  be  the  pancreas 
increased  somewhat  in  size  and  at  the  same  time  in  hardness, 
forming  quite  a  tumour-like  body,  which  rendered  it  extremely 
improbable  that  there  was  a  mistake  as  to  the  structure 
affected.  As  to  the  Uver,  there  was  no  greater  enlargement 
of  it  than  could  be  explained  by  the  obstruction  to  its  biUar}' 
outflow.  No  nodules  or  inequahties  were  felt  on  its  surface. 
The  distended  gall-bladder  was  felt  as  a  pyriform  elastic  body, 
not  in  its  usual  anatomical  position,  but  in  the  axillary  hne 
immediately  under  the  tenth  rib  at  its  most  dependent 
part. 

"The  jaundice  had  not  existed  long  when  the  patient 
began  to  complain  somewhat  bitterly  of  a  general  sense  of 
malaise  and  discomfort,   and  of  aversion  to  food  from  a 


250  THE   LIVER 

persistent  nausea.  Owing  to  continuous  discomfort,  and 
from  the  belief  that  the  case  was  one  of  pure  pancreatic 
malignant  disease,  I  represented  to  her  the  possibility  of 
having  her  symptoms  alleviated  and  the  jaundice  removed 
by  means  of  an  operation,  while  not  holding  out  any  expecta- 
tion of  complete  and  radical  cure.  She  was  hopeful  that  the 
jaundice  would  pass  off,  and  regarded  her  age— 85  years — 
as  too  advanced  to  entertain  the  suggestion  of  operation, 
and  I  made  no  further  reference  to  it.  Things  went  on  thus 
for  some  three  months,  the  discomfort  becoming  greater, 
the  patient's  strength  necessarily  progressively  diminishing, 
and  emaciation  slowly  but  steadily  advancing.  In  fact,  so 
great  was  the  general  sense  of  discomfort,  due  to  the  deepen- 
ing cholaemia,  that  she  began  to  press  me  to  have  the  opera- 
tion undertaken.  I  was  very  loath  to  entertain  the  idea  at 
this  stage,  as  her  general  condition  had  so  deteriorated  that 
I  doubted  the  possibility  of  the  operation  being  moderately 
or  temporarily  successful ;  however,  she  was  so  anxious  to 
have  it  done,  and  both  she  and  her  friends  were  so  willing 
to  run  the  risk  which  I  quite  plainly  and  clearly  put  before 
them,  that  I  asked  my  surgical  colleague  Mr.  Cotterill  if 
he  would  be  willing  to  give  her  what  small  chance  there 
was. 

"Her  admission  to  Mr.  Cotterill's ward,  on  25th  September, 
was  necessarily  followed  by  a  reconsideration  of  the  diagnosis, 
and  my  position  was  that  the  case  was  one  of  primary 
cancer  of  the  head  of  the  pancreas  ;  that  there  was  an  entire 
absence  of  evidence  that  the  stomach  or  liver  was  the  seat 
of  further  malignant  disease ;  that  the  tumour  in  the 
axillary  line  was  the  gall-bladder,  and  not  any  other  organ  ; 
that  the  disease  appeared  so  confined  to  the  head  of  the 
pancreas  that  I  did  not  think  it  had  extended  along  the  bile- 
duct,  so  as  to  occlude  the  cystic  duct ;  that,  therefore,  to 
tap  the  gall-bladder  would  effectively  drain  the  retained 
bile  ;  and  that,  if  the  operation  could  be  performed  with  any 
measure  of  surgical  propriety,  it  might  be  risked. 

"Unfortunately,  after  admission  to  the  Infirmary  various 
untoward  symptoms  developed,  which  made  the  prospect 


JAUNDICE  251 

of  success  still  more  doubtful ;  and  it  was  only  after  very 
full  deliberation,  and  with  many  misgivings,  that  the  opera- 
tion was  performed. 

"  I  need  not  dwell  upon  the  care  and  manipulative  skill 
with  which  Mr.  Cotterill  did  the  operation.  The  steps  of 
and  the  method  of  operation  in  a  case  of  this  kind  belong 
entirely  to  the  surgeon.  Unfortunately,  although  not  un- 
expectedly, the  patient  only  lived  for  thirty  hours  after 
the  operation,  and  it  was  at  least  doubtful  if  she  would 
have  lived  longer  had  she  not  been  operated  upon.  At  the 
post-mortem  examination  the  diagnosis  was  confirmed  in 
every  detail,  and  the  seat  of  operation  showed  that  nothing 
untoward  had  occurred  there  to  hasten  death. 

"  I  would  not  have  thought  of  submitting  in  some  detail 
a  solitary  case  of  unsuccessful  operation  upon  the  gall- 
bladder, undertaken  largely  at  my  request,  were  it  not 
that  it  raises  the  important  question  whether  this  is  an  opera- 
tion which  we  are  to  regard  as  legitimate  merely  as  a  paUi- 
ative  measure.  The  question  might  be  regarded  as  being 
answered  in  the  negative,  to  judge  from  the  meagreness 
of  the  literature  dealing  mth  it,  at  least  so  far  as  I  have 
been  able  to  find.  Operations  upon  the  gall-bladder  for 
the  removal  of  calcuh  as  a  cause  of  jaundice  or  of  colic  have, 
of  course,  been  frequent  in  more  recent  years,  and  the 
successes  have  firmly  estabhshed  the  procedure  as  warrant- 
able, and  even  necessary.  Exploratory  operations  have 
also  been  performed  in  cases  which  have  been  found  to  be 
mahgnant ;  but,  as  I  have  said,  there  is  a  dearth  of  records 
of  operations  deliberately  undertaken  for  the  relief  of  the 
jaundice  caused  by  malignant  obstruction.  The  point 
is  one  on  which  it  is  desirable  to  form  an  opinion  which  can 
be  apphed  in  suitable  cases,  if,  indeed,  we  are  to  grant  the 
operation  to  be  at  all  a  justifiable  one.  Personally,  I  am 
decidedly  disposed  to  favour  it.  I  think  an  operation  for 
the  rehef  of  the  misery  and  discomfort  of  a  deepening 
cholcemia  is  as  humane  a  procedure  as  tracheotomy  in  malig- 
nant laryngeal  disease,  as  gastrostomy  for  malignant 
oesophageal  stricture,   or  entered omy  or  enterostomy  for 


252  THE   LIVER 

malignant  intestinal  obstruction  ;  and  I  do  not  see  why  we 
should  shrink  more  from  the  one  than  from  the  other.  In 
Mrs.  L.'s  case,  had  the  operation  been  performed  at  the  time 
I  recommended  it,  the  patient's  life  might  have  been  pro- 
longed ;  but,  even  if  it  had  not  materially  lengthened  life,  it 
would  have  made  months  of  life  more  endurable,  and  have 
saved  her  much  of  that  languor,  weariness,  and  nausea  which 
were  a  daily  and  hourly  burden.  The  advisability  of  opera- 
tion would,  of  course,  depend  partly  upon  the  possibility  of 
making  a  diagnosis  which  could  reasonably  be  regarded  as 
accurate  and  complete.  If  the  obstruction  to  the  bile- 
duct  were  above  the  cystic  duct,  operative  interference 
would  be  ineffectual ;  but  with  obstruction  below  that  point, 
draining  the  gall-bladder  would  remove  the  jaundice.  A 
distended  gall-bladder  would  thus  indicate  and  warrant 
operation. 

"Then  there  is  the  question  as  to  the  influence  involve- 
ment of  the  stomach  should  have  upon  the  question,  and  I 
should  put  it  thus  :  If  the  gastric  s3rmptoms  are  not  only 
prominent,  but  clearly  attributable  to  gross  involvement  of 
that  organ,  the  removal  of  the  jaundice  would  not  give  suffi- 
cient relief  to  warrant  the  operation.  If,  on  the  other  hand, 
as  was  the  case  in  my  patient,  the  gastric  symptoms  appeared 
to  be  due  rather  to  the  jaundice  than  to  coarse  lesion,  the 
relief  of  the  jaundice  would  be  followed  by  gastiic  relief. 
The  presence  of  duodenal  lesion  would  not  contra-indicate 
operation.  Even  clear  involvement  of  the  liver  would  not 
necessarily  be  a  contra-indication  so  long  as  the  distension 
of  the  gall-bladder  showed  that  the  hepatic  ducts  were  not 
blocked.  The  most  perfect  cases  for  the  operation  would, 
of  course,  be  those  in  which,  as  in  my  case,  the  lesion  was 
confined  to  the  head  of  the  pancreas,  and  these  are  by  no 
means  uncommon." 

Hypertrophic  or  Biliary  Cirrhosis  of  Liver 

This  condition  also  gives  rise  to  jaundice.  It  is  not  a 
common  affection  of  the  liver,  and  it  is  not  dealt  with  here 


JAUNDICE  253 

as  it  is  fully  discussed  in  the  chapter  devoted  to  the  considera- 
tion of  the  various  forms  of  cirrhosis  of  that  organ. 


New-growths  in  the  Liver  or  Outside  it  Pressing 
UPON  the  Bile  Duct 

These  two  conditions  as  a  cause  of  jaundice  can  be 
considered  together.  As  regards  malignant  disease  in  the 
liver  it  must  not  be  thought,  as  is  not  uncommon,  that  it 
always  causes  jaundice.  The  majority  of  cases  of  cancer 
of  the  hver  never  develop  jaundice.  When  jaundice  is 
caused  by  cancer  of  the  liver  it  always  indicates  that  one  of 
the  cancer  masses  is  so  situated  as  to  compress  the  hepatic 
ducts  and  when  it  does  so  it  will  be  found  to  be  on  the  under 
surface  of  the  Hver  near  the  hilum.  A  growth,  developing 
outside  the  liver  and  growing  in  the  same  direction  has 
a  hke  effect.  In  both  cases  there  is  seldom  any  great 
difficulty  in  determining  by  palpation  that  a  tumour  exists. 
There  may  be  some  special  expertness  required  to  deter- 
mine with  precision  the  exact  part  from  which  the  tumour 
may  be  growing,  but  that  is  not  really  a  question  of  great 
practical  moment.  One  point,  hoM^ever,  is  of  practical 
importance,  namely,  that  it  is  desirable  to  be  sure  that  the 
swelling  is  not  a  hydatid  cyst  or  a  collection  of  pus.  Both 
these  are  doubtless  rare,  but  the  possibiHty  of  their  occur- 
rence cannot  altogether  be  ignored.  The  examination  of 
the  blood  will  determine  the  one,  and  the  wise  but  bold  use 
of  the  exploring  needle  may  determine  either.  In  jaundice 
from  any  of  these  causes  the  common  duct  may  not  be 
occluded,  so  that,  while  the  bile  does  not  enter  the  duodenum, 
the  pancreatic  secretion  may,  leading  to  a  corresponding 
difference  in  the  character  of  the  stools. 

Treatment. — ^There  is  nothing  to  do  in  mahgnant  cases 
save  to  alleviate  symptoms  as  far  as  possible  on  general 
principles.  In  the  case  of  hydatids  the  aspirator  can  be 
used  to  empty  a  cyst  and  even  surgical  interference  may  be 
warranted.  In  the  case  of  abscess  it  has  to  be  treated  on 
general  surgical  principles.     If  there  is  any  doubt   as  to 


254  THE  LIVER 

whether  the  tumour  can  be  removed  a  laparotomy  is 
permissible.  \Vlien  everything  points  to  the  condition 
being  malignant,  and  this  view  is  supported  by  expert 
medical  opinion,  I  think  the  advising  of  exploratory  opera- 
tion fatuous  in  the  extreme.  I  have  myself  consented  in 
times  past  to  such  a  proceeding  when  it  was  the  assured 
conviction  of  myself  and  two  other  experts  that  the  causation 
was  malignant  and  inoperable,  but  the  possibility  of  being 
wrong  is  in  reahty  too  shadowy  to  vv^arrant  our  subjecting 
patients  to  a  profitless  ordeal.  The  curious  stories  told  of 
strange  cases  of  abdominal  new-growth  which  have  disap- 
peared after  an  exploratory  laparotomy  are  too  rare  to  be 
allowed  seriously  to  influence  our  opinion  or  our  advice. 
The  contention  that  an  exploratory  abdominal  operation 
makes  no  difference  to  the  progress  of  the  case  tends  to 
become  a  surgical  proverb,  and,  Uke  many  proverbs,  is  at 
least  as  false  as  it  is  true.  Unless  there  is  a  reasonable 
presumption  that  benefit  is  to  follow,  a  surgical  operation 
is  not  to  be  approved. 

New-growth  in  the  Duodenum  Involving  the 
Mouth  of  the  Common  Duct 

New-growth  in  this  position  is  rare ;  when  it  is  present 
it  is  practically  always  malignant.  The  growth  may  be 
very  small,  and  yet  cause  jaundice  by  obstruction  if  it  is 
close  to  the  duct  or  in  it.  Cases  of  this  kind  can  hardly 
be  differentiated  from  catarrhal  cases  in  their  earlier  stage. 
If  there  has  been  no  history  of  gastric  or  digestive 
disturbance  preceding  the  jaundice  the  condition  may  be 
suspected ;  and  if  there  continues  to  be  an  absence  of 
enlargement  or  tenderness  of  the  head  of  the  pancreas  the 
suspicion  becomes  greater.  The  effect  of  treatment  directed 
to  the  removal  of  duodenal  catarrh  will  materially  influence 
the  ultimate  opinion.  Further,  if  the  obstruction  is  not 
maHgnant,  the  patient  will  not  emaciate  as  rapidly  as  if  it 
were,  and  he  will  not  show  the  early  cachexia. 

Treatment.  —  Neither  medical  nor  surgical  treatment  is 
of  any  avail  in  this  condition. 


JAUNDICE  255 

Animal  Parasites  which  Directly  ok  Indirectly 
LEAD  TO  Occlusion  of  the  Common  Duct 

The  parasites  which  may  possibly  lead  to  jaundice  are 
not  numerous  when  hydatids  are  excluded  as  they  are  here. 
Liver  flukes,  tapeworms,  and  round  worms  are  practically 
the  possessors  of  this  field.  The  diagnosis,  or  the  suspicion 
of  the  nature  of  such  a  case,  depends  upon  the  presence  of 
jaundice,  and  the  discovery  that  it  is  associated  with  any  of 
these  parasites.  In  fact,  when  these  are  found  to  be  associ- 
ated it  is  justifiable  to  assume  that  the  parasite  is  the  cause 
of  the  jaundice.  Many  years  ago,  I  saw  a  Catholic  priest 
who  suffered  from  time  to  time  from  jaundice  which  was  a 
great  annoyance  to  him  ;  and  it  was  only  by  clearing  out  a 
tapeworm,  which  he  harboured,  that  he  was  freed  from  this 
recurring  trouble.  Round  worms  are  perhaps  a  more 
common  cause  of  jaundice,  especially  in  children.  A  round 
worm  may  even  occlude  the  bile  duct  by  getting  into  it ; 
but  more  commonly  the  jaundice  is  the  result  of  a  duodenal 
catarrh  set  up  by  the  parasite's  presence  there. 

Treatment. — The  treatment  is  that  applicable  to  the 
removal  of  the  parasite  knovv^n  to  be  present  and  the  subse- 
quent allaying  of  the  local  catarrh. 

General  Considerations 

When  the  various  causes  of  jaundice  are  thus  reviewed 
it  is  apparent  that  surgical  interference  is  only  of  limited 
utility.  If  differential  diagnosis  is  neglected  the  field  of 
surgical  operation  enlarges  indefinitely.  One's  object,  how- 
ever, all  through  this  book  is  to  indicate  the  lines  along 
which  differential  diagnosis  may  be  attained.  It  often 
appears  to  be  more  difficult  than  it  really  is  from  the  want 
of  precision  in  knowledge  as  to  possible  or  probable  causes. 
When  the  jaundice  is  due  to  new-growth  no  operative  inter- 
ference is  curative  for  the  simple  reason  that  it  is  practically 
always  malignant  and  irremovable.  The  cases  in  which 
surgical  interference  is  called  for  are  gall-stone,  and  cholan- 
gitis or  cystitis,   whether  calculus  be  present  or  not.     In 


256  THE   LIVER 

these  operation  is  to  be  strongly  recommended,  and  in  the 
hands  of  an  expert  surgeon  much  confidence  may  be  reposed 
in  its  completely  curative  result.  Occasionally  cases  occur 
in  which  there  is  a  legitimate  doubt  as  to  whether  gall- 
stone is  the  cause  of  obstruction,  and  whenever  this  exists 
the  patient  ought  to  be  given  the  benefit  of  the  doubt  and 
have  operation  recommended.  In  these  cases  if  there  is  no 
cholangitis,  and  no  stone  is  found,  it  will  only  too  commonly 
be  found  that  malignant  disease  is  the  casual  factor.  Calcu- 
lus and  malignant  disease  may  be  both  present,  while  only 
the  calculus  or  calculi  give  evidence  of  their  presence.  Here 
also  the  doubt,  if  doubt  there  be,  warrants  operation.  In 
all  cases  of  jaundice  where  the  obstruction  can  be  satisfac- 
torily shown  to  be  below  the  origin  of  the  cystic  duct  it 
becomes  a  question  whether  the  patient  is  to  be  advised  to 
have  the  gall-bladder  drained,  simply  with  the  yiew  of  re- 
lieving the  great  discomfort  which  results  from  the  intense 
cholsemia  which  ultimately  develops.  Each  case  has  to  be 
decided  by  considering  its  individual  characters.  The  de- 
cision may  be  left  to  the  patient  after  a  frank  explanation 
as  to  what  may  be  expected  from  operation  under  the 
circumstances.  If  the  operation  is  successful  much  rehef  is 
obtained  for  a  time  at  least,  and  success  may  be  confidently 
looked  for  if  the  operation  is  not  delayed  until  the  patient's 
condition  is  too  unfavourable,  and  the  operation  is  performed 
by  an  experienced  and  capable  surgeon. 

Gall-stone  Colic  without  Jaundice 

When  the  presence  of  gall-stone  leads  to  jaundice  it 
does  so  in  one  or  other  of  two  ways  ;  the  one  way  is  by  the 
stone  being  arrested  in  the  common  duct,  after  having  left 
the  gall-bladder  and  passed  along  the  cystic  duct ;  the  other 
way  is,  while  remaining  in  the  gall-bladder  or  in  the  cystic 
duct,  by  setting  up  cholecystitis  and  cholangitis.  The 
symptoms  which  accompan}^  jaundice,  resulting  directly 
or  indirectly  from  gall-stone,  have  been  considered  in  a 
previous  section,  and  do  not  require  repetition  here.     It  may, 


COLIC   WITHOUT   JAUNDICE  257 

however,  be  noted  that  when  gall-stone  has  led  to  jaundice 
the  diagnosis  that  colic  is  or  was  hepatic  in  origin  is 
assumed.  Gall-stone  does  not  cause  jaundice  without  a 
concurrent  or  recent  attack  of  colic. 

On  the  other  hand,  gall-stone  may  cause  intense  pain 
without  a  trace  of  jaundice,  or  a  trace  of  bile  being  demon- 
strable in  the  urine. 

The  pain  of  gall-stone  colic  is  very  severe,  and  may  be 
so  excruciating  that  the  patient  rolls  about  in  agony.  As  in 
all  conditions  in  which  pain  is  a  symptom,  the  pain  of  biliary 
coUc  varies  greatly  in  its  intensity.  It  may  be  severe  enough 
to  cause  death  from  exhaustion,  or  from  its  reflex  action 
on  the  heart,  especially  if  the  heart  be  feeble.  I  have 
known  this  to  occur  in  an  old  man  who  was  seized  with  coUc 
during  the  night  and  died  before  he  could  be  relieved. 
In  that  case  the  stone  was  found  in  the  ampuUa  of  Vater,  its 
end  projecting  into  the  duodenum.  Ihe  pain,  however,  is 
not  always  so  severe,  but  great  severity  is  its  ordinary 
characteristic.  The  pain  usually  comes  on  suddenly,  and 
is  at  once  intense,  although  it  may  take  some  time  to  reach 
its  maximum. 

The  pain  is  referred  to  the  epigastrium,  to  the  region  of 
the  gall-bladder,  or  of  the  umbihcus  :  it  may  go  right  round 
the  Uver  region  to  the  back,  and  extend  upwards  or  down- 
wards. The  pain  is  mainly  and  chiefly  referred  to  the 
anterior,  rather  than  to  the  lateral  or  posterior  aspect  of  the 
abdomen.  The  abdomen  is  not  held  quite  rigid  but  moves 
with  the  movement  of  the  diaphragm.  There  is  some 
degree  of  surface  hyperaesthesia,  but  it  is  not  extreme. 
Hyperaesthesia  may,  however,  be  present  over  the  greater 
part  of  the  abdomen.  Here,  as  in  other  abdominal  condi- 
tions associated  with  pain,  surface  hyperaesthesia  can  be 
judged  of  by  pinching  the  skin  between  the  thumb  and 
forefinger.  There  is  muscular  rigidity,  but  neither  is  this 
extreme.  On  palpation,  if  it  be  done  gently,  not  too 
precipitately,  giving  time  for  the  surface  hyperaesthesia  to 
lessen,  it  will  be  found  that  there  is  deeply  seated  tenderness 
along  the  hver  edge  and  particularly  over  the  gall-bladder. 

17 


258  THE   LIVER 

The  gall-bladder  can  sometimes  be  distinctly  felt  to  be 
enlarged,  projecting  to  a  variable  extent  beyond  the  Hver 
edge,  and  more  tender  than  any  other  part  of  the  hver  edge. 
The  pain  is  paroxysmal  in  character,  that  is,  it  is  not 
constant,  it  comes  and  goes,  although  in  the  intervals  of 
severe  pain  there  may  be  some  measure  of  dull  aching 
referred  to  the  region  of  the  gall-bladder. 

The  paroxysms  of  severe  pain  are  presumably  due  to  the 
stone  becoming  impacted  or  fixed  at  the  mouth  of  the  cystic 
duct  in  such  a  way  as  to  obstruct  the  mouth  of  the  duct 
and  so  prevent  the  gall-bladder  secretion  escaping.  The 
secretion  accumulates,  and  by  distending  the  bladder 
induces  spasm  contraction  of  its  wall,  this  being  the  imme- 
diate cause  of  the  pain.  The  intermittent  character  of  the 
pain  seems  to  indicate  that  it  is  caused  by  recurring  spasm 
of  the  muscular  coat  of  the  gall-bladder,  and  not  by  the 
contact  of  the  stone  with  a  mucous  surface  which  is  probably 
insensitive.  The  position  of  the  stone  blocking  the  mouth 
of  the  cystic  duct,  while  the  irritated  mucous  membrane 
is  stimulated  to  hyper-secretion  of  mucus,  almost  certainly 
causes  painful  spasm.  This  explanation  is  further  sup- 
ported by  the  fact  that  the  presence  of  a  stone  in  the 
gall-bladder  not  only  does  not  cause  continuous  pain,  but 
may  never  give  rise  to  severe  coHc.  It  is  not  very  un- 
common to  find  on  post-mortem  examination  a  gaU-bladder 
containing  several,  or  even  many,  calcuH,  without  any 
record  of  attacks  of  coUc  during  a  period  of  many  years 
before  death. 

An  attack  of  colic  is  sometimes  accompanied  by  an 
abrupt  rise  of  temperature  of  several  degrees  along  with, 
in  some  cases,  a  feehng  of  chilliness,  or  even  of  definite 
rigor,  and  yet  no  jaundice  develops.  Pain  itself  is  sufficient 
to  raise  the  temperature  in  some  adults  ;  but  it  is  a  question 
whether  the  pain  alone,  or  its  association  with  an  inflam- 
matory reaction  of  the  mucous  membrane  and  retained 
secretion,  is  to  be  held  responsible  for  the  febrile  disturbance. 
Case  70  (Mrs.  H.)  illustrates  this  point.  She  had  a 
severe  attack  of  pain   on  two  successive  nights,  on   each 


COLIC   WITHOUT   JAUNDICE  259 

occasion  accompanied  by  a  sudden  rise  of  temperature  to 
102°  F.,  which  as  suddenly  fell  to  normal  when  the  pain 
was  relieved.  AU  evidence  of  inflammation  subsided  with 
the  disappearance  of  the  pain,  which  no  doubt  also  coincided 
with  the  escape  of  the  fluid  contents  of  the  gall-bladder  by 
way  of  the  cystic  duct. 

In  further  confirmation  of  the  correctness  of  the  fore- 
going explanation  as  to  the  immediate  cause  of  the  pain, 
in  the  class  of  case  under  consideration,  the  case  of  a  patient 
sent  to  me  by  my  colleague  Mr.  Cathcart  may  be  mentioned. 
The  patient  was  a  woman  (Case  71,  Mrs.  A.  D.)  who  had 
been  operated  upon  for  gall-stones  some  time  before.  Several 
months  later  she  again  developed  symptoms  similar  to  those 
she  had  previously  experienced.  She  was  admitted  to  my 
ward  and  I  saw  her  during  two  or  more  attacks  of  pain  of 
great  intensity.  During  the  paroxysm  of  pain  there  was  a 
localized  bulging,  about  the  size  of  a  plum,  in  the  position 
of  the  gall-bladder  ;  it  was  intensely  tender.  With  the 
disappearance  of  the  pain  this  bulging  disappeared  also. 
As,  at  the  operation,  the  gall-bladder  had  been  attached  to 
the  abdominal  wall  there  could  be  no  doubt  that  the  attacks 
were  attacks  of  hepatic  colic  and  that  the  bulging  was  due 
to  distension  of  the  adherent  gall-bladder.  Mr.  Cathcart 
again  operated,  opened  the  gall-bladder  and  removed  the 
stone  which  was  causing  the  trouble.  It  would  hardly  be 
possible  to  have  a  more  definite  proof  and  demonstration 
of  the  true  meaning  of  the  pain  in  these  cases. 


Recurring  Gall-stone  Colic  without  Jaundice  :    One 
Large  Stone  Removed  :    Recovery 

Case  72. — Mrs.  McB.,  aged  35,  was  admitted  at  the  re- 
quest of  Dr.  Badger,  Penicuik,  to  the  Royal  Infirmary  on 
the  7th  October,  1909.  She  had  consulted  me  in  the  previous 
July,  on  account  of  pain  she  had  had  in  the  abdomen.  She 
also  spoke  of  "  a  lump  "  she  had  felt  in  the  abdomen  which 
was  very  painful  when  touched,  and  was  situated  at  a  spot 
situated  to  the  right  of  the  middle  fine  and  about  two  inches 


26o  THE  LIVER 

below  the  costal  margin.  Later  it  was  ascertained  that  the 
pain  referred  to  had  come  on  suddenly  whilst  at  work  and  was 
so  severe  that  she  had  to  go  to  bed.  Laudanum  internally 
and  hot  local  apphcations  relieved  her  in  the  course  of  twelve 
hours.  On  examination  of  the  abdomen  nothing  abnormal 
was  discovered  either  in  connection  with  the  Hver  or  the 
kidney  at  that  time.  She  gave  a  history  of  dysmenorrhoea. 
Shortly  after  I  had  seen  her  she  had  a  similar  attack  and  she 
had  several  subsequent  attacks,  and  her  doctor  informed  me 
that  he  had  several  times  felt  the  "  tumour  "  in  the  upper 
right  section  of  the  abdomen.  The  attacks  of  pain  had  been 
very  severe.  On  questioning  her  after  admission  she  was  verj^ 
confident  that  the  attacks  of  pain  were  associated  with  her 
menstrual  periods.  She  was  a  very  intelligent  woman  and 
in  view  of  the  fact  that  no  enlargement  of  the  gall-bladder 
was  detectable,  and  but  very  sHght  tenderness  could  be 
elicited  on  pressure  over  the  gall-bladder,  Mr.  Bre-wds  was 
asked  to  make  a  thorough  examination  of  the  pelvic  viscera, 
which  he  did  under  chlorofonn  and  reported  that  there  was 
nothing  abnormal  in  that  region.  She  was  kept  in  hospital 
and  allowed  to  be  out  of  bed.  On  the  15th  October  she  had 
an  attack  of  pain  and  the  house  physician  felt  a  tender  lump 
in  the  region  of  the  gall-bladder  associated  with  some  tense- 
ness of  the  right  rectus  muscle.  On  the  24th  pain  again 
came  on  in  the  region  indicated,  although  not  severe,  and 
there  was  tenseness  of  the  rectus  as  befoire,  and  the  gall- 
bladder could  be  felt  beyond  the  liver  margin.  It  was 
painful  on  pressure.  The  pain  continued  on  the  following 
days.  The  pain  was  not  nearly  so  severe  as  during  the 
previous  attacks  ;  there  was  no  elevation  of  temperature  ; 
there  was  no  jaundice  and  no  bile  in  the  urine.  A  diagnosis 
of  gall-stone  was  made  and  arrangements  were  made  with 
Mr.  Wallace  that  she  should  be  operated  on.  The  operation 
was  performed  on  the  29th  October.  The  gall-bladder  was 
found  to  project  about  an  inch  beyond  the  liver  edge,  it  had 
formed  adhesions  to  the  liver  and  its  wall  was  considerably 
thickened.  One  large  stone  was  found  and  removed.  She 
made  an  excellent  recovery.     The  case  was  of  interest  from 


COLIC   WITHOUT   JAUNDICE  261 

the  misleading  nature  of  the  patient's  confident  assertion  that 
the  attacks  of  pain  preceded  the  menstrual  periods.  Mr. 
Brewis'  examination,  and  Dr.  Badger's  confidence  that  he 
had  felt  a  tumour  which  might  be  the  gall-bladder,  led  us  to 
wait  for  the  reappearance  of  symptoms,  and,  in  Httle  over  a 
fortnight  from  the  date  of  admission,  the  diagnosis  was 
practically  assured ;  and  there  was  no  longer  any  doubt  as 
to  the  necessity  of  having  the  stone  or  stones  removed. 


Recurring  Gall-stone   Colic  for  Four  Months  :    No 
Jaundice  :    Operation  Successful 

Case  73. — Mrs.  M.,  aged  32,  was  sent  to  my  ward  on  the 
29th  January,  1917.  She  complained  of  attacks  of  abdominal 
pain  and  vomiting  which  frequently  recurred.  These 
symptoms  might  continue  for  a  week,  after  which  there 
would  be  a  period  of  rehef,  perhaps  for  three  weeks,  during 
which  time  she  could  attend  to  her  domestic  duties  until 
another  attack  came  on.  Taking  food  seemed  to  have  no 
influence  in  producing  an  attack  or  remo\dng  it.  An  attack 
might  come  on  late  at  night  or  early  in  the  morning.  The 
pain  was  felt  in  the  epigastrium  and  right  hypochondrium 
and  went  through  to  the  back.  For  the  rehef  of  pain  morphia 
had  been  given  hypodermicaUy.  There  was  and  had  been  no 
jaundice.  My  colleague  Mr.  Miles  operated  on  this  patient 
and  removed  five  gall-stones.  She,  of  course,  made  a  good 
recovery. 

Acute  Cholecystitis  with  Calculus  :    No  Jaundice 
Necrosis  of  Gall-Bladder  :   Operation  :   Recovery 

Case  74. — Mrs.  W.  was  seen  in  consultation  on  the  24th 
October.  On  the  21st  she  got  chiUed  when  waiting  at  a 
railway  station  and  arrived  home  feehng  pain  in  the  right 
hypochondrium  and  sick.  Morphine  reheved  the  pain  and 
made  her  feel  well  enough  to  go  to  church  the  following  day. 
On  Monday  pain  returned  and  continued  aU  day  and  there 
was  vomiting.     I  saw  her  the  following  day  and  got  the 


262  THE  LIVER 

preceding  histor}^  There  was  no  history  of  any  previous 
attack  of  the  kind.  There  was  no  jaundice  and  no  bile  in  the 
urine.  The  abdomen  was  not  tender  all  over.  There  was 
no  tenderness  on  deep  palpation  over  the  caecum.  There 
was  pronounced  tenderness  under  the  hver  edge  where  the 
gall-bladder  seemed  to  be  felt.  The  temperature  ranged 
between  ioo°  and  102°  F.  The  tongue  showed  a  slight  white 
fur,  and  a  dose  of  calomel  had  been  given.  My  diagnosis  was 
cholecystitis  \^ith  gall-stone.  The  treatment  suggested  was 
the  administration  of  morphine  and  atropine  to  relieve  pain, 
hot  appHcations  to  the  hypochondrium,  and  the  evacuation 
of  the  colon  by  means  of  enemata.  Operation  seemed  to  be 
inevitable,  so  Professor  Caird's  assistance  was  requested. 
We  agreed  to  postponement,  but  by  the  27th  it  was  clear 
that  operation  was  imperative  for  there  was  no  abatement 
in  the  cystitis  and  the  pain  continued.  On  opening  the 
abdomen  the  greater  part  of  the  anterior  wall  of  the  gall- 
bladder appeared  necrosed  and  almost  sloughing.  After 
protecting  surrounding  parts  the  gall-bladder  was  opened  and 
twelve  or  more  calcuh  removed.  The  gall-bladder  was  cut 
away.  The  prognosis,  owing  to  the  state  of  the  gall-bladder, 
was  grave,  but  the  patient  made  a  perfect  and  a  speedy 
recovery.  The  case  illustrates  the  fact  that  a  cholecystitis 
may  not  extend  to  the  ducts,  even  when  the  inflammation  is 
so  acute  and  so  virulent  as  to  lead  to  sloughing.  It  is  the 
only  case  of  such  severe  cholecystitis  the  writer  has  seen. 

Gall-stone  Colic  :  No  Jaundice  :  Stone  Removed  from 
Bile  Duct  :    Recovery 

Case  75. — Mr.  S.  was  sent  from  the  South  of  Scotland 
into  a  nursing  home  for  observation.  He  had  suffered 
intermittently  for  months  from  severe  attacks  of  abdomnial 
pain,  but  as  jaundice  had  never  appeared  there  was  the  not 
unusual  hesitation  in  determining  the  cause  of  the  pain. 
Examination  of  the  abdomen  showed  no  stomach  dilatation, 
no  epigastric  tenderness  at  any  point,  no  tenderness  on 
careful  and  deep  manipulation  of  the  caecal  region,  and  no 


COLIC   WITHOUT  JAUNDICE  263 

renal-region  tenderness.  There  was  no  history  of  digestive 
stomach  disturbance ;  the  pain  was  referred  to  the  hepatic 
region,  it  was  paroxysmal  in  character,  coming  on  suddenly, 
and  of  great  intensity.  There  was  no  doubt  that  the  attacks 
were  attacks  of  severe  biliary  colic.  During  a  short  stay  in 
the  nursing  home  there  was  no  attack  and  he  returned  to 
his  own  home.  I  suggested  to  his  doctor  that  the  attacks,  if 
theyreturned,  ought  to  be  treated  with  morphine  and  atropine 
for  the  relief  of  pain  and  spasm  and  that  the  stone  might 
pass.  Some  weeks  later  he  was  sent  back  to  me  as  the 
attacks  of  pain  continued  although  no  jaundice  had  developed. 
There  was  still  no  objective  phenomena  save  that  some  days 
there  was  bile  in  the  fseces,  other  days  there  was  none.  Mr. 
Stuart,  one  of  my  junior  surgical  colleagues,  saw  the  patient 
at  his  own  house,  for  the  patient  was  able  to  walk  there. 
Mr.  Stuart  hesitated  about  the  diagnosis,  but  a  severe  attack 
of  pain  in  his  presence  removed  doubt.  On  the  following 
day  the  operation  revealed  a  stone  in  the  ductus  choledochus. 
It  was  removed  with  great  skill,  if  a  physician  may  be  allowed 
to  form  a  judgment  on  the  manipulative  skill  of  a  surgeon 
faced  by  an  operation  that  appeals  to  him  as  requiring  great 
care  and  nicety.  The  patient  made  an  uninterrupted  and 
speedy  recovery. 

Remarks. — ^The  entire  absence  of  jaundice  in  this  case  was 
explained  by  the  bile,  accumulated  and  retained  behind  the 
stone,  from  time  to  time  getting  past  the  obstruction  ;  this 
also  explained  the  presence  and  the  absence  of  bile  from  the 
faeces.  It  was  also  notable  that  a  stone  of  such  a  size 
should  have  travelled  so  far  without  setting  up  cholecystitis 
or  cholangitis.  It  very  strikingly  illustrated  what  I  have 
laid  so  much  emphasis  on,  namely,  that  bihary  colic  must 
be  diagnosed  quite  apart  from  jaundice.  That  jaundice  is  a 
necessary  accompaniment  of,  or  sequel  to,  gall-stone  colic 
has  to  be  given  up  in  practical  medicine.  It  also  illustrated 
the  fact  that  a  large  stone  may  pass  along  the  large  bile  ducts. 
Reference  has  elsewhere  been  made  to  the  case  of  an  old 
man  who  died  in  an  attack  of  gall-stone  colic,  in  whom,  at  the 
post-mortem  examination,  the  stone  was  found  in  the  ampulla 


264  THE  LIVER 

of  Vater,  its  end  projecting  into  the  duodenum.  The  stone 
was  about  the  size  and  shape  of  a  date  stone.  In  that  case 
there  was  no  history  of  severe  abdominal  pain  until  the 
paroxysm  which  killed  him  came  on ;  but  he  was  an  old  man 
who  spent  most  of  the  time  in  bed.  In  this  other  case  the 
patient  had  no  attack  of  pain  when  in  bed  in  the  nursing 
home,  but  walking  to  seethe  surgeon  determined  an  opportune 
attack  in  the  surgeon's  consulting-room. 

AU  this  it  is  necessary  to  reahze,  for  it  shows  that  pre- 
cipitate surgical  interposition,  as  soon  as  the  diagnosis  is 
reached  of  bihary  cohc,  is  not  necessary.  The  history  is 
really  the  factor  which  ought  to  determine  whether  the  time 
for  surgical  assistance  has  or  has  not  arrived.  The  case  of  a 
lady  whom  I  saw  when  writing  the  foregoing  further  illustrates 
this  point. 

Case  76. — I  was  asked  to  see  a  lady  about  60  years  of  age 
who  was  in  a  nursing  home.  Her  doctor,  Dr.  W.  Elder,  in- 
formed me  that  she  had  her  first  attack  of  gaU-stone  coUc 
three  years  before.  Until  a  week  before  I  saw  her  she  had  been 
entirely  free  of  pain  for  two  years,  but  for  a  week  she  had 
suffered  from  severe  pain,  which  had  been  controlled  by  the 
administration  of  morphine.  She  had  not  been  jaundiced. 
She  was  sent  into  the  nursing  home  with  a  view  to  operation. 
When  I  saw  her  she  had  been  free  from  pain  for  two  or  three 
days.  There  was  no  abdominal  pain  and  not  the  slightest 
tenderness  along  the  Hver  edge  or  in  any  part  of  the  abdomen. 
The  patient  was  highly  intelligent,  and  when,  going  into  the 
history  minutely,  it  was  suggested  to  her  that  a  stone  often 
passed,  she  promptly  said  that  her  feehng  had  been  as  if 
something  were  passing  and  that  she  felt  as  if  it  had  passed, 
the  rehef  of  pain  was  so  instantaneous.  This  is  a  fairly 
common  experience,  and  the  teaching  of  such  cases  is  that  a 
stone  passes,  that  another  may  form  after  a  long  interval  and 
it  also  may  pass.  I  can  look  back  upon  cases  free  for  many 
years  from  biliary  coHc  after  a  single  severe  attack.  In  some 
cases  the  stone  is  found  in  the  faeces,  but  sufficient  care  in  the 
search  for  it  cannot  always  be  ensured.  In  the  case  at 
present   being  considered  1  entirely  agreed  with  Professor 


COLIC   WITHOUT   JAUNDICE  265 

Caird  that  aU  thought  of  operation  had  to  be  postponed. 
The  indication  in  cases  of  this  description,  is  to  use  the 
measures  which  are  available  to  prevent  the  formation  of 
calculi. 

The  following  case  is  added  because  the  configuration  of 
the  abdomen  and  the  unusually  low  position  of  the  gall- 
bladder gave  rise  to  doubt  as  to  the  nature  of  the  lump  which 
was  felt. 

Case  77. — J.  M.,  aged  59,  was  sent  to  the  Infirmary  in 
December,  191 8.  Five  days  before  admission  he  was  seized 
with  sudden  and  severe  pain  in  the  abdomen,  which  he  located 
between  the  anterior  spine  of  the  ihum  on  the  right  side  and 
the  umbiHcus.  The  pain 
lasted  all  night.  WTien 
his  medical  attendant 
examined  him  he  found 
a  "  lump  "  in  the  posi- 
tion indicated,  and  ad- 
vised him  to  go  to  the 
Infirmary.  On  inquiring 
into  the  patient's  his- 
tory it  was  ascertained 
that  six  years  before  he  Fig.  34.— Case  77.    G.B.,  gall-bladder;   U, 

had  had  an  attack  of  |iS™-J:  ^M^^^StKar^Tn:  '■"- 
pain    in    the   abdomen, 

which  lasted  only  a  short  time,  and  the  cause  of  which  was 
not  clear.  Three  years  and  four  years  later  he  had  similar 
attacks  of  pain  which  lasted  longer.  He  was  a  big,  powerful, 
well-nourished  man.  On  examination  of  the  abdomen  the 
"  lump  "  was  easily  felt.  It  was  not  tender,  and  it  moved 
with  respiration.  The  position  of  it  is  shown  in  Fig. 
34.  The  figure  is  reduced  from  the  tracing  taken  at  the 
time  of  examination,  and  taken  in  the  manner  described  in 
an  earher  chapter.  At  first  it  was  not  apparent  that  the 
lump  was  connected  with  the  Hver ;  it  was  clearly  not 
connected  with  the  caecum,  and  it  was  not  a  displaced  kidney. 
It  was  quite  superficial.  The  possibihty  of  its  being  a 
neoplasm    in    the    great  omentum  suggested  itself,   while 


266  THE   LIVER 

the  attack  of  pain  could  be  attributed  to  a  temporary  twisting 
of  the  pedicle  of  the  neoplasm.  Later  it  was  decided  that  it 
was  connected  with  the  liver  and  was  therefore  the  gall- 
bladder, and  that  the  pain  was  due  to  calculus.  That 
operation  was  required  in  either  case  was  not  questioned. 
Mr.  Miles  opened  the  abdomen  and  removed  a  large  stone 
from  the  gall-bladder.     The  patient  made  a  good  recovery. 

Conclusions 

The  conclusions  arrived  at  may  be  summarized  as  follows. 

(i)  The  three  most  common  causes  of  jaundice  are : 
{a)  duodenal  catarrh  ;  {b)  gall-stone,  either  directly 
or  indirectly  by  setting  up  cholangitis,  which  may 
be  due  to  gall-stone  injury  to  the  ducts,  or  to  exten- 
sion from  a  cholecystitis  set  up  by  a  retained  stone  ; 
and  (c)  cancer  of  the  head  of  the  pancreas. 

(2)  The  diagnosis  of  gall-stone  coHc  has  frequently  to  be 

made  without  the  presence  of  jaundice  ;  and  it  is 
usually  easy  to  distinguish  it  from  pain  due  to  other 
causes. 

(3)  Cholecystitis     and     cholangitis     are    preceded    or 

accompanied  by  gall-stone  colic,  and  the  tempera- 
ture is  raised.  If  there  is  no  jaundice  the  in- 
flammatorj^  action  is  confined  to  the  gall-bladder, 
and  the  stone  or  stones  have  riot  left  the  gall- 
bladder. 

(4)  Gall-stone  may  pass. 

(5)  If  the  stone  or  stones  do  not  pass,  and  are  causing 

pain;  or  there  is  cholecystitis  or  cholangitis, 
operation  is  necessary  for  removal  of  stone  or  for 
drainage  of  the  gall-bladder  and  the  bile  ducts. 


CHAPTER  XXI 

THE   CIRRHOSES   OF   THE   LIVER 

The  cirrhoses  of  the  liver  are  commonly  grouped  in  three 
classes,  namely,  first,  Laennec's  atrophic  cirrhosis — the 
common  cirrhosis  producing  the  hob-nail  Hver ;  second, 
Hanot's  hypertrophic  or  bihary  cirrhosis ;  and,  third, 
syphihtic  cirrhosis.  These  have  synonyms  based  upon  the 
leading  histological  change  they  present ;  thus  the  first  is 
polylobular  cirrhosis,  in  virtue  of  the  fibrous  tissue  surround- 
ing several  lobules  ;  the  second  is  monolobular  or  biUary 
cirrhosis,  as  the  fibrous  tissue  surrounds  individual  lobules 
and  there  is  a  seeming  increase  of  bile  ducts  in  the  portal 
spaces  ;  the  third  is  pericellular  or  intralobular,  because  the 
fibrous  tissue  appears  simultaneously  throughout  individual 
lobules  and  thus  surrounds  groups  of  liver  cells. 

On  the  clinical  side  it  is  commonly  taught  that  these 
have  the  following  distinctive  features  : — Atrophic  cirrhosis 
shows  diminution  in  the  size  of  the  organ  as  judged  by 
percussion  ;  a  hard  nodular  edge  or  surface  when  within 
reach  of  the  palpating  hand  ;  ascites,  emaciation,  and  no  or 
but  sUght  jaundice,  and  this  present  only  in  the  advanced 
stage.  Hypertrophic  cirrhosis  is  characterized  by  enlarge- 
ment of  the  organ  as  revealed  by  percussion  ;  a  smooth 
surface  and  edge  revealed  by  palpation  ;  no  ascites,  marked 
jaundice.  Syphilitic  cirrhosis  may  present  the  chnical 
features  of  either  of  the  preceding  ;  the  liver  may  have  a 
lobulated  surface  from  the  development  of  fibrous  strands 
in  it,  and  perihepatitis  is  common. 

From  the  etiological  standpoint  the  atrophic  form  is 
usually  attributed  to  the  imbibition  of  alcohol  which  reaches 

267 


26S  THE  LIVER 

the  Kver,  and  acts  through  the  portal  blood  upon  the  fibrous 
tissue  of  the  portal  spaces  ;   the  hypertrophic  is  refen-ed  to 

influences  acting  from  the  bile  ducts  upon  the  surrounding 
fibrous  tissue,  while  the  invoh'ement  of  the  bile  ducts  is  the 
cause  of  the  jaundice  which  is  so  prominent  a  feature  in  this 
form. 

Clinical  and  anatomical  difficulties  which  have  arisen  in 
connection  ^^ith  cirrhosis  are  to  be  attributed  to  the  classical 
descriptions  given  of  the  atrophic  and  hypertrophic  forms 
respectively.  Speaking  of  Hanot's  description  of  hyper- 
trophic cirrhosis,  Cheadle  sa^^s  (Lumleian  Lectures,  1900, 
On  Some  Cirrhoses  of  the  Liver)  :  "It  is  surprising  how  a 
definite  observation  of  this  kind,  stated  \rith  authority,  holds 
swaj',  and  its  general  apphcation  remains  unquestioned,  as 
aU-comprehensive,  -without  further  examination  or  inquiry." 
This  comment  can  ^\ith  equal  force  be  appUed  to  other 
conditions  and  descriptions,  and  there  is  no  doubt  that  the 
first  definitions  of  diseased  processes  may  greatly  hamper 
the  acceptance  of  later  and  more  complete  observations  and 
the  inferences  which  foUow  from  them.  Names  become 
associated  'S'sith  definite  clinical  manifestations,  and  proposed 
rearrangements  are  slowly  accepted.  Appl5ring  this  to  the 
matter  at  present  under  consideration,  it  appears  to  me  that 
the  difficulties  which  have  arisen  centre  round  the  term 
'*  h5-pertrophic  "  given  by  Hanot.  The  word  is  used  to 
designate  an  enlarged  hver,  in  contradistinction  to  the 
"  atrophic  "  or  smaU  hver  of  Laennec.  The  two  t^^es  of 
cirrhosis  thus  defined  became  fixed ;  but,  as  experience  has 
viidened  and  investigations  have  multipHed,  it  has  become 
increasingly  apparent  that  the  terms  atrophic  and  hyper- 
trophic do  not  necessarily  carry  \^ith  them  either  the  chnical 
manifestations  or  the  histological  characters  which  authority 
associated  with  them.  This  divergence  from  the  t\-pe  as 
originaU}-  fixed  is  most  marked  in  the  enlarged  or  "  h^T)er- 
trophic  ' '  form.  A  hver  may  be  enlarged,  and  therefore 
clinically,  although  strictty  speaking  inacciurately,  be  termed 
"  h3-pertrophic, "  and  this  hj-pertrophic  form  may  not 
show   jaundice,    may    be    coarsely   nodulated,    may   have 


CIRRHOSES   OF   THE   LIVER  269 

ascites,  may  not  show  an  increase  of  bile  canaliculi,  and  the 
fibrous  tissue  may  have  a  polylobular  distribution.  This 
perturbs  the  equilibrium  of  both  the  cUnician  and  patho- 
logist, and  it  does  so  because  it  is  authoritatively  taught  that 
an  enlarged  cirrhotic  liver  ought  not  to  be  a  coarse  polylobular 
cirrhosis  and  ought  to  cause  jaundice.  Again,  a  liver  is 
met  with  which  is  small  and  atrophic,  but  the  fibrous  tissue 
may  be  diffusely  increased  and  mainly  monolobular  in 
distribution,  so  that  it  is  a  finely  granular  instead  of  a  coarsely 
granular  organ,  and  there  may  be  a  marked  richness  of  bile 
canalicuh  in  the  fibrous  tissue,  yet  there  is  no  jaundice,  and 
there  is  ascites.  Here,  then,  is  an  atrophic  fiver  with  the 
minute  structure  of  a  hypertrophic  one,  and  the  confusion 
seems  to  become  hopeless. 

It  has  been  shown  by  the  published  observations  of  various 
inquirers  that  a  hypertrophic  fiver  may  exist  without  the 
cfinical  phenomena  or  the  histological  characters  associated 
with  it  in  Hanot's  classical  description.     Murchison,  Saimdby, 
FoxweU  and  Cheadle  have  aU  shown  this  to  be  the  case,  and 
others  have  reached  a  similar  conclusion.     In  fact,  the  evi- 
dence is  so  strong  that  the  matter  is  no    longer  open  to 
question.     But  while  this  change  of  view  has  become  neces- 
sary, it  is  to  be  noted  that  the  change  attaches  itself  to  the 
question  of  size  as  expressed  in  the  term  "  hypertrophic." 
The  standpoint  of  mere  size  is  often  a  very  unrefiable  one 
in  medicine,  and,  as  we  have  pointed  out,  it  is  so  when  hepatic 
cirrhoses  are  considered.     If,  however,  the  standpoint  be 
altered,  the  whole  question  assumes  a  different  aspect.     If 
instead  of  size  being  the  standard  the  existence  of  marked 
jaundice  be  taken,  we  arrive  at  a  distinction  w^hich  is  more 
important  and  has  a  more  sound  etiological  significance. 
The  cirrhoses  without  jaundice  are  those  which  are  commonly, 
and  probably  correctly,  referred  to  blood  changes  in  the 
portal  circulation,  but  the  resulting  cirrhosis  may  lead  to 
a  large  or  a  small  liver,  to  a  coarse  or  a  finely  granular  surface, 
to  fibrous  tissue,  rich  or  poor  in  bile  canaficufi.     On  the  other 
hand,  cirrhosis  associated  with  marked  jaundice  is  a  true 
biliary  cirrhosis  ;  that  is  to  say,  it  has  its  starting-point,  not 


270  THE   LIVER 

in  blood  changes  in  the  portal  circulation,  but  in  conditions 
in  the  excretory  ducts  of  the  liver  in  some  part  of  their  course. 
These  changes  interfere  mth  the  removal  of  bile,  not  with  its 
formation  :  to  produce  jaundice  in  cirrhosis,  bile  has  to  be 
formed  and  then  absorbed  into  the  circulation  as  such. 
Here  then  it  seems  to  me  is  a  crucial  and  essential  distinction 
both  from  a  clinical  and  a  pathological  standpoint.  A  saving 
clause  has  to  be  added  here,  as  in  so  many  other  conditions 
where  boundaries  are  laid  down,  and  the  reservation  in 
cirrhosis  is  that  the  common  cirrhosis  may  interfere  with 
bile  ducts  so  as  to  cause  a  measure  of  jaundice,  but  this  is  a 
secondary  complication  and  not  the  initial  change.  Cheadle 
says  that  of  fifty- three  fatal  cases  of  cirrhosis  of  all  kinds  at 
St.  Mary's,  marked  jaundice  was  only  noted  in  eight,  and  in 
only  four  of  these  was  the  liver  small,  while  in  four  it  was 
large  [loc.  cit.  p.  17). 

The  proposition  that  the  confusion  regarding  cirrhosis  is 
removed  by  abandoning  the  ordinary  clinical  concept  based 
upon  size,  and  substituting  for  it  another  factor,  namely 
jaundice,  requires  some  further  consideration. 

Hanot  and  Charcot  both  recognized  a  large  hver  with 
jaundice,  the  cause  of  which  was  obscure.  In  this  large 
liver  the  cirrhosis  was  monolobular,  and  there  were  many 
bile  ducts  in  the  fibrous  tissue.  Charcot  and  Gombault 
further  recognized  a  cirrhosis  with  jaundice  due  to  obstruc- 
tion to  the  outflow  of  bile  and  with  the  macroscopic  and 
microscopic  characters  of  Hanot's  hypertrophic  biliary 
form.  Numerous  experimental  investigations  have  been 
undertaken  with  a  view  to  determine  the  effect  of  occlusion 
by  Hgature  of  the  main  bile  duct.  Wickham  Legg  {St. 
Bartholomew's  Hospital  Reports,  vol.  ix.  1873)  in  this  country, 
Charcot  in  France  [Arch,  de  Physiologie,  1876),  Maffucci 
of  Naples  in  1882,  and  more  recently  Vaughan  Harley 
{Brit.  Med.  Jour.  1898,  vol.  ii.),  have  all  done  so,  and  the 
result  has  been  to  show  that  occlusion  leads  to  enlargement 
of  the  hver,  jaundice,  and  a  cirrhosis  which  is  monolobular 
in  distribution  and  more  or  less  rich  in  bile  canalicuU. 
Nicoti    and    Richard    {Arch,    de    Physiologie,    1880)    have 


CIRRHOSES   OF   THE   LIVER  271 

described  an  analogous  condition  in  the  liver  of  dogs  due 
to  parasites  obstructing  the  hepatic  ducts. 

From  the  clinical  side  Wickham  Legg  {Trans.  Path.  Soc. 
Lond.  1874) ,  Charcot  and  others  have  shown  that  obstruction 
to  the  bile  outflow  in  man  leads  to  corresponding  Uver 
changes.  The  former  has  also  shown  that  in  congenital 
imperviousness  of  the  common  duct  a  Hke  result  is  produced. 
Ford  of  Montreal  has  recently  {American  Jour.  Med.  Sciences, 
January,  1901)  written  an  excellent  resume  on  Obstructive 
Biliary  Cirrhosis,  in  which  he  records  the  results  of  a  detailed 
examination  of  three  cases  which  occurred  in  that  city,  and 
in  which  he  confirms  the  observations  made  by  the  authors 
already  referred  to.  One  of  the  points  upon  which  he  dwells 
is  that  the  so-called  increase  of  bile  ducts  in  the  fibrous 
tissue  is  not  of  that  nature,  but  that  the  appearances  which 
have  been  so  interpreted  are  caused  by  the  fibrous  tissue 
surrounding  groups  and  rows  of  cells  which  become  altered 
in  appearance  and  thus  give  a  false  resemblance  to  bile 
ducts.  He  on  this  point  agrees  with  Findlay  {Brit.  Med. 
Jour.  1900,  vol.  i.)  and  others.  Ford's  observations  entirely 
agree  with  my  own,  and  I  fully  concur  with  him  as  to  the 
mode  of  formation  of  many  of  the  so-called  bile  ducts.  It 
may,  however,  be  that  the  appearance  is  in  part  due  to  the 
persistence  of  rows  of  cells  which  contain  a  bile  ductule, 
while  the  cells  not  containing  a  ductule  perish  by  compression. 
This  is  practically  what  Cheadle  refers  to  as  the  "  exposure 
of  existing  ones  (ductules)  by  denudation  through  the 
destruction  of  hepatic  cells  "  {loc.  cit.  p.  8).  The  theory  of 
proliferation  of  bile  ducts  as  a  compensatory  process  to 
obstruction  has  always  seemed  to  me  to  be  quite  unreason- 
able, and  as  having  no  analogy  in  any  other  organ.  What- 
ever view  be  held,  it  is,  however,  certain  that  the  appearance 
in  question  is  not  confined  to  cases  in  which  there  is  obstruc- 
tion to  bile  outflow. 

From  the  foregoing  it  must  be  accepted  that  the  changes 
which  result  from  obstruction  to  the  outflow  of  bile  are,  as 
Ford,  and  others  before  him,  have  pointed  out,  similar 
and   indistinguishable    from    those    described    in    Hanot's 


272  .     THE   LIVER 

h\'pertrophic  biliary  cirrhosis.  Cheadle,  strangely  enough, 
says  "  that  in  the  majority  of  cases  of  obstructive  jaundice, 
even  when  prolonged,  no  cirrhosis  follows  "  [loc.  cit.  p.  34). 
My  own  experience  is  in  opposition  to  Cheadle  and  in  accord 
witla.  Ford. 

This  point  being  estabhshed,  the  question  is  suggested  : 
Is  Hanot's  h}"pertrophic  biharj^  cirrhosis  a  clinical  and  patho- 
logical entity  apart  from  obstructive  biliary  cirrhosis  ?  It 
is  difl&cult  to  arrive  at  a  perfectly  satisfactory  answer  to  this 
question.  Cheadle  and  others  consider  that  it  must  be  a 
very  exceptional  condition,  judging  from  their  own 
experience.  This,  I  think,  will  be  found  to  be  the  common 
experience  in  Britain.  The  idea  is  that  the  true  Hanot's 
cirrhosis  is  a  primary  and  probably  infective  inflammation 
of  the  bile  ducts.  The  acceptance  of  this  view  allows  the 
changes  in  the  hver  to  be  interpreted  as  due  to  obstruction, 
but  indicates  piimar}'  duct  inflammation  as  the  cause  of  the 
obstruction.  This,  again,  raises  the  question  as  to  the 
determining  cause  of  the  duct  inflammation.  There  is 
evidence  to  show  that  the  passage  of  a  calculus,  which  has 
escaped  into  the  duodenum,  may  leave  behind  an  infective 
inflanamation  of  the  ducts  which  can  cause  a  catarrhal  block 
of  them  o^^ing  to  the  low  pressure  at  which  the  bile  flows. 
I  have  seen  a  case  where  the  draining  of  an  inflamed  gall- 
bladder, where  no  stone  was  found  either  in  it  or  in  the 
ducts,  led  to  the  recovery  of  the  patient  and  the  removal  of 
the  jaundice,  the  jaundice  ha^dng  apparently  been  caused  by 
an  inflammatory  occlusion  of  the  hepatic  ducts,  which  was 
cured  by  drainage  of  the  inflamed  gaU-bladder,  this  drain- 
age draining  the  ducts  also.  From  facts  of  this  kind  the 
question  ma}-  be  asked  if  Hanot's  pure  t3-pe  is  at  all  deserving 
of  a  special  clinical  position,  and  if  it  is  not  possible  that 
most  of  the  cases  so  classed  were  set  up  by  a  primar}^  coarse 
lesion  to  a  duct  by  the  passage  of  a  stone.  At  the  same  time, 
the  possibihty  of  a  true  primary  infective  choleangitis 
cannot  be  entirely  put  aside  as  never  occurring,  especially 
in  \dew  of  the  fact  that  the  occurrence  of  a  true  primary 
infective  cholecystitis  is,  I  take  it,  now  clearly  estabhshed. 


CIRRHOSES   OF  THE   LIVER  273 

If  the  foregoing  argument  is  based  on  well-established 
facts,  which  I  believe  it  is,  the  questions  surrounding  liver 
cirrhosis  would  be  resolved  as  follows  : — 

The  primary  and  most  important  phenomenon  would  be 
the  presence  of,  or  the  time  of  the  development  of,  jaundice. 
If  there  were  no  jaundice,  or  if  it  supervened  as  a  late 
symptom,  the  Hver  might  be  large  or  small,  and  the  terms 
"  hypertrophic  "  and  "  atrophic  "  may  be  applied  as  hither- 
to. It  ought,  however,  to  be  clearly  understood  that  these 
terms  signify  nothing  more  than  size. 

If,  on  the  other  hand,  jaundice  be  an  early  and  a  marked 
feature,  and  the  liver  be  enlarged,  then  Hanot's  term, 
"  hypertrophic  biliary  cirrhosis,"  ought  to  be  applied  to  the 
condition.  This,  according  to  the  preceding  argument, 
is  true  biliary  cirrhosis,  and  usually  presents  itself  as  a  clinical 
entity  with  early  jaundice,  enlargement,  and  no  ascites ; 
and  as  a  pathological  entity  characterized  by  enlargement, 
bile  coloration,  a  finely  granular  surface,  a  monolobular 
cirrhosis,  and  an  increase  of  so-called  bile  ducts  in  the  portal 
spaces.  This  "  biliary  cirrhosis  "is,  I  think,  always  "  hyper- 
trophic," meaning  thereby  enlargement.  The  condition 
to  which  we  would  thus  confine  Hanot's  term  is,  as  we  have 
seen,  identical  in  its  cHnical  and  anatomical  characters  with 
"  obstructive  biliary  cirrhosis,"  as  produced  experimentally 
in  animals  and  as  found  not  infrequently  in  man.  It  has 
indeed  been  further  shown  in  this  connection  that  in  the  small 
number  of  cases  in  which  a  cause  for  the  jaundice  had  not 
been  determined  that  it  was  almost  certainly  due  to  blockage 
of  the  bile  ducts  from  a  primary  and  initial  inflammation 
of  them,  or  secondary  to  an  antecedent  and  perhaps  over- 
looked history,  indicating  the  passage  of  a  gall-stone.  The 
infective  nature  of  some  cases  of  the  typical  Hanot's  hj^er- 
trophic  biliary  cirrhosis  has  been  investigated  recently  by 
N.  N.  Kirckow  {St.  Petersburger  Med.  Woch.,  No.  38,  1900) 
and  others,  but  the  bacteriology  of  the  condition  cannot  at 
present  be  gone  into. 

All  this,  however,  leads  to  a  matter  of  very  great  practical 
interest,  and  that  is  the  clinical  significance  of  the  "  atrophic  " 

18 


274  THE   LIVER 

and  "  hypertrophic  "  cirrhosis,  as  I  have  defined  them,  and 
which  are  not  associated  with  early  and  marked  jaundice  ; 
or,  in  other  words,  the  significance  of  cirrhosis  with  the 
liver  enlarged  in  one  case  and  diminished  in  size  in  another. 
The  latest  utterance  on  this  question,  so  far  as  I  know,  is 
to  be  found  in  Dr.  Cheadle's  Lumleian  Lectures,  to  which 
reference  has  already  been  repeatedly  made.  The  outcome 
of  his  experience  is  to  show  that  if  enlargement  is  due  to 
syphilis  it  can  be  treated  with  marked  success  ;  further, 
that  cirrhosis  with  enlargement,  even  when  unmistakably 
alcoholic  in  origin,  yields  more  satisfactory  results  from 
repeated  tappings  and  other  approprate  measures  than 
cirrhosis  with  atrophy.  He  holds  that  the  enlarged  liver 
indicates  a  more  acute  cirrhosis,  and  that  it  is  in  virtue  of 
this  fact  that  treatment  is  more  successful  than  in  the  chronic 
atrophic  form.  This  gives  a  practical  and  a  therapeutic 
differential  importance  to  the  "  atrophic  "  and  the  "  hj^er- 
trophic  "  cirrhosis  if  the  term  "  hypertrophic  "  is  to  be 
accepted  as  having  this  restricted  application. 

I  have  not  dealt  in  detail  with  syphilitic  cirrhosis,  for  it 
does  not  occur  as  a  diffuse  condition  in  the  adult.  Hepatic 
sj^mptoms  due  to  syphilis  are  the  outcome  of  gumma,  the 
cicatrices  they  leave,  and  of  perihepatitis  and  the  adhesions 
and  contractions  caused  thereby. 

Clinical  Manifestations  o!  Atrophic  Cirrhosis.— The  fore- 
going discussion  on  the  types  of  cirrhosis  of  the  hver  was 
written  a  number  of  years  ago,  but  it  holds  equally  good  for 
the  present.  It  is  only  necessary  to  amphfy  somewhat  the 
clinical  side  of  the  commonest,  namely,  the  atrophic  form. 
\Vhile  this  form  is  usually  the  result  of  the  free  use  of  alcohol, 
cases  are  seen  in  which  not  only  no  history  of  alcohohsm  can 
be  obtained,  but  the  evidence  is  opposed  to  this  as  the  cause 
of  the  change.  When  alcoholism  is  the  cause  the  earher 
symptoms  are  not  the  early  symptoms  of  cirrhosis  but  of 
digestive  disturbance  due  to  the  imbibition  of  alcohol. 
The  presence  of  gastric  and  other  symptoms  from  this  cause 
ought  to  lead  to  very  strong  representations  being  made  by 
the  medical  attendant  as  to  the  absolute  necessity  of  a  change 


CIRRHOSES   OF   THE   LIVER  275 

of  habit,  if  liver  atrophy  is  to  be  prevented.  WTien  cirrhosis 
is  not  alcohoHc  it  does  not  seem  to  be  preceded  by  pro- 
nounced symptoms  of  digestive  disturbance.  In  hospital 
practice  cases  of  atrophic  cirrhosis  are  not  seen,  usually, 
until  there  is  some  fluid  in  the  abdominal  cavity,  indeed  the 
amount  of  fluid  may  be  great.  Before  fluid  is  poured  out 
cirrhosis  has  been  already  established,  and  the  size  of  the 
liver  diminished.  The  diminution  in  size  is,  however,  not 
satisfactorily  determined  by  percussion,  unless  it  is  pro- 
nounced. The  reason  of  this  is  the  variable  size  of  the 
organ,  and  the  variety  of  type  of  abdomen.  The  presence 
of  fluid,  on  the  other  hand,  is  of  outstanding  significance. 
On  the  subject  of  ascites  it  is  necessary  to  be  somewhat 
critical,  as  some  of  the  teaching  which  has  been  handed  down 
from  the  past  is  not  correct.  The  most  pronounced  cases 
may  be  taken  first.  In  these  the  abdomen  is  much  dis- 
tended and  bulged  anteriorly  and  laterally ;  percussion 
is  dull  from  the  flanks  upwards,  as  far  as  the  fluid  has 
risen,  and  also  in  the  hypogastrium.  A  fluid  wave  can  be 
produced  and  felt  wherever  the  fluid  is  ;  and  even  from  one 
side  of  the  abdomen  to  the  other,  by  placing  the  hand  over 
one  flank  while  the  other  flank  is  tapped  by  a  finger  of  the 
other  hand.  The  level  of  the  fluid  changes  with  change  of 
position  ;  if  the  patient  turns  from  the  dorsal  position  to 
one  side,  the  fluid  gravitates  to  that  side,  and  the  dullness  on 
percussion  rises  to  a  level  nearer  to  the  level  of  the  umbilicus. 
This  time-honoured  procedure  is  not  necessary,  however,  and 
is  often  inconvenient.  The  fluid  wave  is  absolute  evidence 
of  the  existence  of  ascites.  In  small  amounts  of  fluid  the 
wave  cannot  be  produced  across  the  abdomen  ;  but  it  is 
easily  produced  when  one  hand  rests  on  the  surface  of  the 
iliac  region  while  the  finger  of  the  other  hand  taps  the 
abdomen  above  that.  When  fluid  is  present  the  wave 
can  be  obtained  from  above  downwards  and  from  below 
upwards. 

There  is  frequently  quite  unnecessary  hesitancy  in  diag- 
nosing fluid,  when  the  fluid  \\-ave  cannot  be  obtained  across 
the  abdomen.     The  presence  of  a  small  quantity  of  fluid  is 


276  THE   LIVER 

readily  diagnosed   after  a   little   experience   of  the   above 
method  of  examining  for  its  presence. 

When  an  abdomen  is  distended,  the  distension  is  due 
either  to  gas  or  air  in  the  intestines,  to  fluid  in  the  peritoneal 
cavity,  or  to  neoplasm.  Neoplasm  can  be  felt  as  a  hard 
mass.  Fluid  can  be  distinguished  from  gas  and  its  presence 
put  beyond  doubt  by  the  method  described.  The  importance 
of  being  quite  sure  that  an  abdomen  contains  fluid,  or  does 
not,  is  this,  that  if  fluid  be  present  we  are  then  in  a  position 
to  consider  the  local  causes  which  lead  to  fluid  being  poured 
out  here  and  nowhere  else,  that  is  to  say  the  production  of  a 
pure  ascites,  not  ascites  merely  part  of  an  anasarca  from 
heart  or  kidney  disease.  A  pure  ascites  is  a  local  condition 
and  has  therefore  a  local  cause.  The  diseases  in  which 
ascites  occurs  may  for  ordinary  clinical  purposes  be  Umited 
to  three  ;  {a)  tuberculosis  of  the  peritoneum,  [h)  diffuse 
malignant  disease  of  the  peritoneum,  and  (c)  atrophic  cir- 
rhosis of  the  Uver.  If  the  two  first  can  be  excluded  there  is 
only  cirrhosis  to  consider  and  one  has  practically  reached  the 
position  that  ascites  is  due  to  cirrhosis,  unless  history  and 
symptoms  point  to  malignancy  or  tuberculosis. 


CHAPTER  XXII 

MALIGNANT    DISEASE   OF   LIVER 

The  liver  is  frequently  the  seat  of  malignant  neoplasm. 
The  new-growth  may  be  primary  or  secondary.  Secondary 
growths  are  more  frequently  seen  than  primary  ;  but  this 
fact  must  not  be  allowed  to  hamper  or  hinder  diagnosis. 

Secondary  growth  may  be  a  metastasis  from  almost  any 
organ  ;  but  most  commonly  the  primary  growth  is  in  the 
abdomen.  Not  infrequently  a  diagnosis  of  malignant 
disease  has  been  arrived  at  before  there  is  any  evidence  of 
the  liver  being  involved.  The  primary  growth  is  often  in 
the  stomach,  but  it  may  be  in  any  part  of  the  intestine  where 
m^alignancy  occurs.  When  malignancy  has  been  diagnosed 
elsewhere  than  in  the  Uver  involvement  of  the  liver  may 
determine  whether  or  no  surgical  interposition  is  to  be  useful 
or  helpful.  In,  for  instance,  malignant  disease  of  the  body 
of  the  stomach  with  secondary  involvement  of  the  liver  no 
useful  purpose  could  be  served  by  operation.  In  the  case, 
however,  of  malignancy  at  the  pylorus  with  consequent 
obstruction  a  gastro-enterostomy  would  give  relief  and 
prolong  hfe  even  in  the  case  of  involvement  of  the  Hver. 

When  malignant  disease  has  been  diagnosed  in  some 
other  viscus  than  the  Uver,  signs  of  hver  involvement  may 
or  may  not  be  present,  but  the  absence  of  signs  is  no  proof 
that  the  hver  is  free.  The  reason  of  this  is  that  many 
nodules  of  new-growth  may  be  present  without  appreciable 
enlargement  of  the  organ.  And  further,  the  nodules  of  new- 
growth  must  be  on  the  surface  of  the  organ  to  render  them 
palpable,  and  they  are  by  no  means  always  so  situated.  It 
follows  that  involvement  of  the  hver  can  only  be  diagnosed 

277 


278  THE  LIVER 

by  enlargement,  or  b}^  nodules  on  the  surface  large  enough 
to  produce  palpable  projections. 

^"\^len,  on  the  other  hand,  malignant  neoplasm  is  primary 
in  this  organ  the  diagnosis  does  not  follow  quite  such  simple 
Hnes,  and  it  is  this  form  which  requires  fuller  considera- 
tion. The  onset  of  mahgnant  growth  does  not  seem  to  be 
heralded  bj-  an}-  definite  s3Tnptoms.  Its  advance  soon, 
however,  begins  to  produce  an  unwonted  sense  of  weakness, 
interpreted  as  being  "  run  down,"  "  out  of  condition," 
"  over-worked,"  as  "  needing  a  rest."  The  appetite  may 
have  failed.  There  maj'  be  a  complaint  of  "  getting  thin- 
ner." The  skilled  eye  may  detect  a  suggestion  of  cachexia. 
There  is  no  stomach  sjTnptom  beyond  the  impairment  of 
appetite.  There  are  no  intestinal  or  rectal  symptoms  ; 
none  referable  to  thoracic  structures  ;  none  to  the  bladder. 
If  this  has  been  the  history  for  weeks,  perhaps  for  two  months 
or  longer,  there  are  usually  signs  to  be  found  on  examination 
of  the  abdomen.  The  Hver  or  part  of  it  is  palpable.  It  is 
most  important  to  realize  this  distinction,  for  enlargement 
may  be  confined  to  the  left  lobe,  or  it  may  aAect  only  the 
portion  of  the  right  lobe  in  contact  ^ith  the  parietes.  In 
some  cases,  though  rarely,  the  whole  organ  is  enlarged. 
With  enlargement  of  any  part  there  is  nearly  always  a  loss 
of  surface  smoothness  over  the  area  affected.  The  degree 
of  this  varies  considerably^,  and  is  determined  by  the  number 
and  the  rate  of  growth  of  individual  nodules.  Sometimes 
there  are  numerous  small  nodules  giving  the  affected  portion 
the  feeling  of  a  coarse  cirrhosis,  at  other  times  the  masses 
are  larger,  or  there  maj^  appear  to  be  only  one  great  lump. 
The  growth  may  be  on  either  side  of  the  suspensory  ligament 
when  the  enlargement  is  found  to  be  in  the  epigastrium  and 
the  surface  is  uneven.  As  a  rule  there  is  no  tenderness  on 
palpation.  The  involvement  of  only  part  of  the  liver  may 
lead  to  difficult}'  in  diagnosis.  I  have  seen  the  left  lobe  so 
much  enlarged,  distorted  in  shape,  and  reaching  so  far  down 
in  the  abdomen  that  it  was  difficult  to  persuade  one's  self 
that  it  was  liver  and  not  something  else.  In  the  right 
lobe  a  mass  may  be  so  situated  as  to  raise  the  question 


MALIGNANT   DISEASE   OF   LIVER  279 

whether  it  is  Hver  or  kidney.  This  point  in  diagnosis  is 
dealt  with  in  a  later  chapter,  in  which  kidney  conditions  on 
the  right  side  are  discussed.  With  such  phenomena  and  a 
history  of  progressing  debility  there  is  practically  no  doubt 
as  to  the  diagnosis. 

In  making  a  diagnosis  the  only  other  conditions  which 
ought  to  be  kept  in  mind  are  two  in  number.  The  first 
of  these  is  the  presence  of  a  gumma  on  the  surface  of  the 
liver  giving  rise  to  a  projection.  Such  a  lesion  causes  pain 
and  is  tender  on  palpation.  In  these  respects  it  differs 
from  malignant  disease.  If  there  is  any  doubt  the  use  of 
mercurial  ointment  locally  will  remove  the  one  and  have  no 
effect  upon  the  other.  The  second  condition  is  stiU  more 
uncommon  in  this  country,  namely,  a  large  hydatid  cyst. 
This  may  lead  to  a  large  projection  on  the  surface  of  the 
organ  which  is  not  painful  or  tender  to  touch  and  has  not 
produced  any  constitutional  disturbance.  Such  localized 
swelling  is  almost  certainly  a  hydatid  cyst.  The  absence 
of  aU  constitutional  disturbance  not  only  excludes  malig- 
nancy but  also  abscess.  A  hydatid  cyst  showing  on  the 
surface  can  be  successfully  dealt  with  by  the  surgeon. 

It  is  thus  seen  that  the  diagnosis  does  not  present  diffi- 
culties of  outstanding  significance. 

The  malignant  neoplasm  enlarges  rapidly  and  is  accom- 
panied by  progressive  cachexia.  In  a  few  cases  the  enlarge- 
ment is  very  rapid  and  very  great.  In  a  case  of  "  chorion 
epithelioma "  under  my  care  the  enlargement  ended  in 
rupture,  the  patient  dying  of  haemorrhage  into  the  abdominal 
cavity. 

There  seems  to  be  an  idea  fairly  prevalent  that  malignant 
disease  of  the  hver  causes  jaundice.  It  seldom  does  so. 
Jaundice  only  occurs  if  the  neoplasm  is  situated  on  the 
under  surface  of  the  organ  and  in  such  a  position  as  to  press 
upon  the  bile  duct  in  the  hepatic  fissure.  \Vhen  it  is  situated 
thus  it  presses  also  upon  the  portal  vein  and  causes  ascites. 


Section  VI.— THE  SPLEEN 
CHAPTER  XXin 

ENLARGEMENT  :  SPLENOMEGALY 

The  spleen  is  enlarged  in  many  conditions,  but  the  degree  of 
enlargement  varies.  In  typhoid  fever  and  in  pernicious 
anaemia  there  is  enlargement,  but  never  to  any  great  size.  In 
both  varieties  of  leukaemia,  on  the  other  hand,  the  organ  may 
attain  a  very  large  size  ;  in  chronic  malaria  it  may  also 
become  greatly  enlarged.  In  so-called  splenic  anaemia,  or 
Banti's  disease,  the  increase  is  pronounced.  With  the  excep- 
tion of  these  three  conditions  there  is  no  other  condition 
in  which  great  enlargement  occurs.  Considerable  enlarge- 
ment used  to  be  met  with  in  waxy  degeneration,  but 
such  cases  have  become  very  rare,  at  least  in  the  adult. 
When  the  organ  is  enlarged  the  enlargement  is  made  out 
by  percussion  and  in  more  pronounced  cases  by  palpation 
as  well.  The  organ  for  which  it  is  most  readily,  and 
perhaps  commonly,  mistaken  is  the  kidney ;  or,  to  put 
it  more  directly,  an  enlarged  spleen  is  thought  to  be  kidney 
and  vice  versa.  This  mistake  is  illustrated  in  a  later  chapter, 
and  as  this  was  being  prepared  for  the  press  I  saw  a  patient 
with  a  great  mass  on  the  left  side  of  the  abdomen  which 
was  believed  to  be  spleen,  although  physical  examination 
was  not  conclusive.  The  mass  extended  up  under  the 
ribs,  it  had  a  definite  anterior  edge  with  two  indentations, 
but  the  upper  part  was  uneven  and  nodular.  There  was 
progressive  loss  of  weight,  no  rise  of  temperature,  and  a 
progressive  increase  in  size  of  the  mass.  There  were  no 
urinary  symptoms.  On  examination  of  the  blood  it  was  at 
once  shown  that  the  patient  was  suffering  from  an  acute 

280 


ENLARGEMENT:  SPLENOMEGALY     281 

lymphatic  leucocythaemia.  Before  the  blood  was  examined 
in  this  case  the  question  arose  as  to  what  other  pathological 
condition  produced  a  spleen  of  such  immense  size  ?  Mahgnant 
disease  is  often  a  ready  answer  ;  but  the  question  then  is : 
Does  malignant  disease  ever  appear  primarily  in  the  spleen 
and,  if  it  does,  can  primary  or  secondary  growth  ever  lead 
to  such  enlargement  ?  The  answer  for  all  practical  and 
clinical  purposes  is  in  the  negative.  If  on  blood  examination 
this  mass  had  been  found  not  to  be  associated  with  leucocy- 
thaemia or  marked  anaemia,  it  could  not  be  spleen,  in  spite 
of  its  resemblance  to  that  organ,  and  if  not  spleen  there  was 
no  organ  it  could  be  but  kidney,  in  a  male  patient.  In  a 
female  it  might  have  been  a  vagrant  ovarian  tumour.  In 
this  patient  all  these  questions  were  settled  by  a  blood 
examination.  The  same  error  may  also  be  made  in  the  case 
of  a  moderately  enlarged  spleen.  A  moderately  enlarged 
spleen  gives  an  increase  in  the  area  of  normal  percussion 
dullness,  the  area  extending  upwards  and  forwards  ;  the 
lower  pole  projects  from  under  the  left  costal  margin,  is 
ovoid  in  shape,  has  a  smooth  surface,  and  moves  with 
respiration.  It  is  not  palpable  bimanuaUy  with  one  hand 
in  the  loin  as  a  kidney  of  the  same  degree  of  enlargement 
would  be  palpable,  and  the  lower  pole  is  in  contact  with  the 
parietes  as  it  comes  from  under  the  costal  edge,  as  a  kidney 
at  this  stage  of  enlargement  never  is. 

The  differentiation  from  neoplasm  at  the  splenic  flexure 
of  the  colon  has  to  be  reached  in  the  first  place  by  the  simple 
fact  that  malignant  disease  at  this  flexure  probably  never 
produces  a  mass  that  has  any  resemblance  to  the  lower  pole 
of  a  spleen,  and  in  the  second  place  by  the  history.  IMalignant 
disease  at  this  flexure  never  attains  palpable  size  without  a 
history  of  recurring  attacks  of  obstruction,  or  of  attacks  of 
arrest  of  colon  evacuation  overcome  with  great  difficulty, 
accompanied  sometimes  by  vomiting.  On  examination 
evidence  will  be  found  of  faecal  accumulation  in  the  colon 
behind  the  seat  of  obstruction. 

When  all  these  points  are  taken  into  consideration  there 
is  really  no  reasonable  difficulty  in  recognizing  a  moderately 


282  THE   SPLEEN 

enlarged  spleen  ;  it  is  only  when  there  is  great  enlargement 
that  there  is  difficulty  in  distinguishing  between  a  kidney  and 
a  spleen.  The  differential  diagnosis  under  these  conditions 
is  dealt  with  in  the  section  devoted  to  the  kidney. 

On  the  left  side  the  problem  is  really  narrowed  to  a 
j  udgment  between  spleen  and  kidney ;  and  when  the  clinical 
facts  are  considered  alongside  the  pathological  possibilities 
the  problem  solves  itself.  Pathological  fancies  and  imagin- 
ings, however,  often  become  barbed-wire  barriers  to  clinical 
progress. 

It  is  not  necessary  to  enlarge  upon  the  recognition  of 
enlargement  of  the  spleen  in  malaria.  An  increase  in  the 
area  of  normal  splenic  dullness,  and  an  intensification  of  the 
dullness  when  a  patient  has  malaria,  is  at  once  accepted  as 
splenic  without  question  ;  and  if  the  lower  pole  of  the  organ 
is  felt  projecting  from  under  the  costal  margin  it  is  taken  as 
a  measure  of  the  enlargement  of  the  organ.  There  is  in  this 
case  no  doubt  entertained,  and  every  student  trained  in 
physical  diagnosis  is  expected  to  be  able  to  make  the 
observations  necessary  for  forming  a  judgment.  Cases  of 
malaria  need  not  therefore  be  recorded  here.  The  follow- 
ing cases  illustrate  some  of  the  points  dealt  with  or 
referred  to. 

Case  78. — A  man,  aged  50,  had  the  abdomen  opened  for 
a  "  tumour  "  in  the  region  we  are  dealing  with.  It  was 
believed  to  be  either  an  enlarged  kidney  or  neoplasm  at  the 
splenic  flexure  of  the  colon.  Nothing  was  found  on  laparo- 
tomy but  an  enlarged  spleen.  He  was  later  sent  to  my  ward 
in  the  Royal  Infirmary.  On  examination  there  was  no 
doubt  about  the  presence  of  "  the  lump  "  ;  and  it  presented 
the  characters  of  a  spleen  projecting  a  couple  of  inches 
beyond  the  costal  margin.  There  was  no  history  of  malaria. 
Examination  of  the  blood  showed  the  usual  picture  of  an 
early  spleno-medullary  leukaemia  with  29,400  white  cells. 
The  patient  was  put  into  the  hands  of  the  electrical  depart- 
ment for  X-ray  treatment.  In  the  course  of  five  weeks  the 
organ  retreated  up  under  the  costal  margin  and  the  area  of 
dullness  became  practically  normal,  the  leucocyte  count  fell 


ENLARGEMENT:  SPLENOMEGALY     283 

to  4250,  and  there  were  no  abnormal  cells  to  be  seen  in  the 
blood.  Two  years  later  he  was  in  perfect  health.  This 
case  from  the  therapeutic  standpoint  is,  unfortunately,  in  my 
experience  unique,  and  the  question  which  it  suggested  was 
whether  it  was  possible  that  opening  the  abdomen  had  been  a 
factor  in  bringing  about  the  result  which  had  followed  on 
X-ray  treatment.  This  question  was  suggested  by  (i)  the 
fact  that  X-ray  treatment  is  not  usually  successful,  and  (2)  by 
the  knowledge  of  the  benefit  following  upon  opening  the 
abdomen  in  tuberculous  disease  of  the  peritoneum  and  in 
some  other  ill-defined  cases. 

Case  79. — Mrs.  T.,  aged  31,  was  sent  in  by  her  doctor  as 
a  case  of  enlarged  spleen,  the  patient  being  definitely  ill. 
The  details  of  this  case  need  not  be  given  here.  The  patient 
was  the  victim  of  a  very  acute  lymphatic  leucocythsemia.  On 
admission  the  blood  examination  showed  the  red  cells  to  be 
3,392,000  and  the  white  cells  42,000,  of  which  go  per  cent,  were 
large  lymphocytes  and  7  per  cent,  polymorphs.  The  spleen 
enlarged  rapidly  and  the  temperature  began  to  swing  to  102° 
and  even  104°  ;  the  white  cells  rose  to  137,600  and  the  reds 
fell  to  a  little  over  2,000,000,  and  the  patient  died.  X-ray 
treatment  could  not  be  used  as  the  first  application  made  all 
the  symptoms  worse. 

Other  cases  of  enlarged*  spleen,  in  either  lymphatic  or 
spleno-medullary  leucocythaemia,  need  not  be  given,  for  it  is 
not  the  purpose  of  this  book  to  dwell  upon  topics  so  well-worn 
and  familiar.  What  has  been  given  here  is  given  to  lay 
emphasis  on  the  necessity  for  blood  examination  in  all  cases 
where  a  mass  in  the  abdomen  is  under  observation.  As  has 
been  already  stated,  when  such  a  mass  is  not  associated  with 
leucocythaemia  it  has  to  be  proved  that  it  is  not  kidney.  It 
further  must  be  borne  in  mind  that  a  leucocytosis  must  be 
carefully  distinguished  from  a  leucocythaemia.  In  some 
inflammator}^  conditions  of  the  kidney  and  its  pelvis,  and  in 
perinephric  inflammation,  there  is  a  marked  leucocytosis. 
Under  the  heading  of  pyonephrosis  the  details  of  a  case  are 
given  in  which  presumably  the  blood  examination  led  to 
serious  error  in  diagnosis. 


Section  VII.— THE   KIDNEY 

CHAPTER   XXIV 

introductory  :   movable  kidney  :  perinephric  abscess 

Introductory 
In  this  section  it  is  not  proposed  to  deal  with  all  the  diseases 
which  occur  in  the  kidneys.  The  various  forms  of  nephritis 
are  excluded.  The  conditions  in  which  palpation  is  an 
essential  part  of  the  examination  are  mainly  dealt  with. 
These  cases  are  first  seen  either  by  the  family  practitioner, 
or  by  the  physician,  and  it  is  often  of  great  importance  to 
the  patient  that  an  accurate  and  an  early  diagnosis  be  made. 
It  must  not,  however,  be  assumed  that  in  some  cases  palpation 
of  the  kidney  region  is  unnecessary,  for  it  ought  to  be  part 
of  the  routine  procedure  whenever  a  full  examination  of  the 
abdomen  is  made  ;  and  this  ought  to  be  made  in  all  abdo- 
minal cases. 

Ordinarily  the  kidney  on  neither  side  is  palpable,  although 
occasional  cases  are  met  with  in  which  the  lower  pole  of  one 
or  other  organ  may  just  be  felt.  Palpation  is  made  by  one 
hand  in  the  loin  and  the  other  over  the  corresponding  region 
in  front.  The  hands  ought  to  be  gently  and  slowly  pressed 
inwards  and  upwards  as  if  they  were  intended  to  meet, 
while  the  patient  is  encouraged  to  breath  easily,  or  to  take 
deeper  breaths,  using  the  lower  part  of  the  chest  or  upper 
part  of  the  abdomen  in  such  a  way  as  to  ensure  move- 
ment of  the  diaphragm.  This  instruction  is  particularly 
necessary  in  the  case  of  women,  as  their  breathing  is  largety 
thoracic. 

With  regard  to  palpation  it  is  to  be  remembered  that  the 

284 


MOVABLE   KIDNEY  285 

kidneys  are  placed  retroperitoneally  and  are  thus  outside 
the  general  peritoneal  cavity.  One  important  result  of  this 
is  that  when  enlarged  they  extend  downwards  and  usually 
backwards,  and  thus  tend  to  fill  up  the  loin  and  to  be  readily 
palpable  by  the  hand  in  the  loin  when  the  hand  in  front  is 
pressed  towards  the  loin.  This  is  so  definite  that  in  many 
cases  there  ought  to  be  no  doubt  that  the  mass  which  is  felt 
is  kidney  and  no  other  organ.  It  is  only  in  cases  of  great 
enlargement  that  doubt  is  reasonable,  and  that  more  detailed 
examination  and  consideration  are  essential.  The  questions 
which  then  require  consideration,  with  a  view  to  differential 
diagnosis,  are  different  for  each  kidney,  but  on  both  sides 
they  are  few  in  number,  and  when  this  is  realized  the  problem 
is  greatly  simplified.  Nothing  has  so  much  obscured,  and 
given  an  aspect  of  unmerited  difficulty,  to  the  diagnosis  of 
abdominal  conditions,  as  the  vague  and  false  impression 
that  anything  may  occur  in  an}^  part  of  the  abdomen. 

When  the  problem  is  faced  practically  and  formulated 
the  difficulties  are  at  least  defined,  and  will  be  found  to  be 
few  in  number.  On  the  left  side  the  first  question  is  :  Is 
the  swelling  kidney,  or  spleen,  or  splenic  flexure  of  the  colon  ? 
On  the  right  side  the  question  is  the  same,  save  that  the  Hver 
takes  the  place  of  the  spleen.  The  problem  is  no  bigger  than 
this  ;  but  it  has  to  be  approached  definitely  from  this  stand- 
point. Here,  as  in  all  abdominal  problems,  the  first  question 
is  which  soHd  organ,  or  which  portion  of  hollow  viscus  is 
affected.  When  that  is  determined  the  disease  or  malady 
in  the  affected  part  falls  to  be  considered  and  a  diagnosis 
arrived  at ;  and  it  will  be  found  at  this  stage  also  that  the 
problem  is  not  so  large,  not  so  diffuse  and  ill-defined,  as  it  is 
commonly  thought  to  be. 

Movable,  Floating  and  Displaced  Kidney 

Movable  Kidney. — Movable  kidney  is  a  very  common 
condition.  It  occurs  in  men  but  much  more  frequently  in 
women.  It  is  present  in  many  women  in  whom  it  gives  rise 
to  no  symptoms  and  no  discomfort.     In  them  it  is  discovered 


286  THE   KIDNEY 

when  the  abdomen  is  examined  for  something  else  ;  and  it  is 
wise  not  to  intimate  the  discovery  to  the  patient,  as  it  may 
be  a  cause  of  mental  anxiety,  in  view  of  the  extreme  opinions 
entertained  regarding  the  condition  in  some  medical  quarters, 
and  in  sections  of  the  community.  If  no  symptoms  are 
referable  to  the  kidney  region  the  matter  ought  to  be  left 
alone.  The  diagnosis  of  mobility  is  usually  easy.  With  the 
hands  placed  deeply,  as  stated  in  the  Introductory  part  of 
this  section,  an  ovoid  smooth  body  may  be  felt,  which  is 
readily  moved  upwards  and  backwards  under  the  pressure 
of  the  hand  in  front.  If  the  patient  can  be  made  to  breathe 
by  means  of  the  diaphragm,  it  moves  down  again,  and  can 
again  be  replaced  by  the  palpating  hand.  A  kidney  is 
nearly  always  tender  when  palpated.  The  amount  of  kidney 
felt  varies,  often  only  the  lower  half  or  third  of  the  organ 
is  felt ;  but  the  whole  kidney  may  be  felt.  In  other  cases 
the  lower  pole  only  of  the  organ  is  felt  with  each  movement 
downwards  of  the  diaphragm,  while  it  retreats  with  expira- 
tion. The  minor  degrees  of  mobility  may  be  missed  and  are 
often  missed  by  npt  realizing  that  the  organ  only  comes 
down  if  the  diaphragm  is  being  actively  used  during 
examination. 

Floating  Kidney. — ^The  term  Floating  Kidney  is  applied 
when  the  organ  has  a  greater  range  of  movement  than  has 
just  been  described.  It  may  be  found  lower  than  the  iliac 
crest  and  yet  be  easily  pushed  upwards  and  backwards  into 
its  normal  position.  The  shape  and  consistence,  the  smooth- 
ness of  surface,  and  the  fact  that  it  can  be  pushed  up  into 
the  loin  make  it  quite  certain  that  what  is  felt  is  kidney. 
Nothing  else  at  aU  Uke  this  occurs  in  this  part  of  the  abdomen. 
The  range  of  movement  of  a  floating  kidney  may  not  be 
limited  to  this  down  and  up  movement ;  it  may  slip  towards 
the  middle  line,  and  I  have  felt  more  than  once  a  kidney  that 
could  be  moved  towards  the  mesial  plane  until  it  partly  rested 
on  the  vertebrae.  In  other  cases  there  is  a  forward  displace- 
ment, so  that  the  organ  may  be  felt  under  the  edge  of  the 
liver,  especially  if  the  patient  is  placed  in  the  prone  position. 


:movable  kidney  287 

Displaced  and  Fixed  Kidney. — In  this  condition  the  kidney 
is  lixed  in  its  abnormal  position.  The  absence  of  mobihty 
on  manipulation  makes  diagnosis  more  difficult.  When  the 
organ  is  as  low  as  or  below  the  iliac  crest  the  possibiHty  of  the 
mass  being  an  ovary  has  to  be  considered  and  the  opinion 
of  the  expert  gynaecologist  may  be  required  and  is  always 
desirable.  When  it  is  fixed  towards  the  middle  line  and  lies 
under  the  edge  of  the  liver  it  may  be  mistaken  for  a  distended 
gall-bladder.  The  converse  mistake  has  also  been  made, 
a  distended  gall-bladder  being  diagnosed  as  an  enlarged  and 
displaced  kidney.  Careful  determination  of  the  position  of 
the  liver  edge  and  the  immobility  of  the  mass  when  deep 
diaphragmatic  breathing  is  exercised  will  help  in  the 
differentiation. 

Symptoms. — In  movable  kidney  there  may  be,  as  already 
stated,  no  symptoms ;  but  when  the  mobility  is  sufficient 
to  warrant  the  term  floating  being  applied  there  may  be 
marked  discomfort  and  even  pain.  The  pain  is  referred  to 
the  half  of  the  abdomen  corresponding  to  the  vagrant  organ, 
it  may  begin  as  a  sense  of  dragging  when  the  patient  is 
upright,  increasing  on  moving  about  and  rendering  walking 
any  distance  impossible  owing  to  increasing  pain.  It  leads 
to  symptoms  commonly  spoken  of  as  neurasthenic,  for,  as 
in  all  painful  abdominal  conditions,  the  general  tone  and 
health  suffer,  appetite  is  impaired,  and  there  may  be  reflex 
disturbances  of  digestion  leading  to  loss  of  weight.  It 
upsets  the  normal  nervous  equilibrium,  the  manifestations 
varying  greatly  in  different  sufferers.  It  may  lead  to  a 
condition  of  chronic  invalidism  as  trying  to  others  as  it  is  to 
the  patient.  Another,  although  by  no  means  an  mvariable, 
result  is  a  kinking  of  the  ureter  due  to  an  alteration  in  the 
axis  of  the  kidney.  This  may  occur  intermittently.  It 
causes  attacks  of  pain,  due  to  retention  of  urine  in  the  pelvis 
and  calices  of  the  kidney,  and  may  lead  to  hydronephrosis. 
Relief  is  obtained  when  the  kink  is  corrected  and  the  urine 
escapes  into  the  ureter.  Hydronephrosis  may  be  permanent 
when  a  displaced  kidney  gets  fixed  in  a  bad  position. 


288  THE   KIDNEY 

Treatment. — Floating  kidney,  or  movable  kidney  which 
gives  rise  to  symptoms,  may  be  kept  in  position  by  means  of  a 
carefully  adjusted  abdominal  corset.  If  this  proves  in- 
effectual the  patient  requires  surgical  assistance.  A  fixed 
hydronephrotic  kidney  which  causes  discomfort  or  pain  can 
only  be  dealt  with  surgically. 

Pathology. — A  few  words  may  be  added  on  the  pathology 
of  the  condition.  It  is  usually  stated  that  a  floating  or 
freely  movable  kidney  has  a  special  mesentery.  I  have  had 
the  opportunity  of  examining  after  death  some  cases  of  this 
kind  and  was  surprised  to  find  that  the  kidney  could  be  freely 
moved  downwards  and  towards  the  middle  line  behind  the 
peritoneum  and  without  showing  any  drag  on  the  peritoneum. 

Acute  Perinephritis  with  Perinephritic  Abscess 

Perinephritis  is  inflammation  of  the  tissues  surrounding 
the  kidney.  The  kidney,  as  has  been  already  stated,  is 
placed  retroperitoneaUy  and  lies  against  the  lumbar  muscles. 
It  is  attached  to  surrounding  structures  by  fibrous  tissue 
which  usually  fixes  it  firmly  in  its  normal  position  in  the 
loin.  In  perinephritis  it  is  this  surrounding  connective 
tissue  which  becomes  acutely  inflamed.  The  inflammatory 
process  may  involve  the  tissue  right  round  the  kidney ;  it 
may,  however,  be  more  circumscribed  arid  confined  to  the 
tissue  behind  the  kidney,  when  it  becomes  retrorenal,  or  above 
the  upper  pole  of  the  kidney,  when  it  becomes  suprarenal. 
The  kidney  itself  is  not  involved  in  the  process.  The  cause 
is  the  presence  of  one  of  the  pyogenic  micro-organisms  ;  but 
whence  it  comes,  and  why  it  reaches  this  region,  are  not 
known,  although  it  is  assumed  that  the  infective  organisms 
have  been  carried  in  the  lymph  stream  from  lower  down  in 
the  abdomen  or  from  the  pelvis.     It  occurs  on  either  side. 

Symptoms. — The  symptoms  at  the  outset  are  a  feeling 
of  chill  or  definite  shivering  with  pain  referred  to  the  loin 
affected.  The  temperature  rises  and  there  are  the  other 
indications   of   an   acute   inflammatory   process.     The  loin 


PERINEPHRITIS  289 

is  tender  and,  later,  painful  on  palpation.  The  blood  shows 
a  polymorphonuclear  leucocytosis.  The  febrile  condition 
continues  and  on  bimanual  examination  the  loin  becomes 
resistant,  filled  up  and  projects  backwards.  There  is  no 
change  in  the  urine  pointing  to  involvement  of  the  kidney 
itself  in  the  acute  inflammatory  process. 

Diagnosis.  —  The  diagnosis  is  very  simple.  An  acute 
febrile  condition  with  pain  and  tenderness  in  the  loin  ;  no 
change  in  the  urine  indicating  acute  inflammation  of  kidney 
tissue  ;  continuation  of  the  febrile  phenomena  ;  the  loin 
remaining  tender  or  pamful  on  manipulation  while  becoming 
fuller,  leaves  no  doubt  as  to  the  diagnosis.  There  is  practically 
no  other  explanation  of  such  phenomena.  The  diagnosis 
ought  not  to  be  delayed  and  treatment  ought  to  follow  in 
due  course. 

Treatment. — The  treatment  belongs  to  the  surgeon. 
The  part  has  to  be  incised  to  give  free  vent  to  the  pus  which 
is  rapidly  produced.     The  treatment  is  completely  curative. 

Illustrative  Cases 

The  following  case  of  retronephric  abscess  is  taken  from 
my  earlier  records  as  it  had  an  unusual  history. 

Case  80. — J.  P.,  aged  27,  brass-moulder,  was  admitted 
to  the  Royal  Infirmary  on  the  4th  October.  The  history 
obtained  showed  that  at  the  age  of  19  he  became  a  journey- 
man brass-caster.  Soon  after  that  he  began  to  have  attacks 
of  pain  in  the  left  lumbar  region  shooting  downwards  to  the 
groin  and  testicle.  These  attacks  did  not  prevent  him  from 
following  his  occupation  until  eight  months  before  admission, 
when  they  had  become  so  severe  and  so  frequent  that  he 
gave  up  his  work  as  a  moulder.  He  then  worked  for  a  few 
months  in  a  coal  pit  and  improved  somewhat  in  general 
health  and  the  attacks  of  pain  lessened  in  frequency  and 
severity.  The  improvement  continued  until  six  weeks  before 
admission,  when  he  was  suddenly  seized  by  a  severe  attack  of 
pain.     For  three  weeks  before  admission  he  had  been  confined 

19 


290  THE  KIDNEY 

to  bed,  attacks  of  pain  occurring  during  the  day  as  well  as 
the  night.  The  pain  was  localized  to  the  lumbar  region  and 
he  compared  it  to  a  "  hot  iron  being  thrust  through  the 
part."  During  the  long  history  of  recurring  attacks  of  pain 
he  stated  that  an  attack  always  caused  frequent  micturition, 
only  a  small  quantity  of  urine  being  passed  at  a  time. 

On  examination  there  was  pain  and  great  tende'rness  in 
the  left  loin,  and  this  loin  was  distinctly  fuller  than  the  right 
one ;  it  gave  the  impression  of  a  tense,  thick-walled  sac. 
It  could  not,  however,  be  felt  by  bimanual  palpation,  and 
pressure  made  deeply  in  front  did  not  cause  pain.  The 
temperature  ranged  from  99 -6°  to  loi  -4°  Fahr.  He  perspired 
profusely  during  the  paroxysms  of  pain  and  also  during 
sleep.     The  urine  was  practically  normal. 

Remarks. — ^There  was  no  room  for  doubt  that  there  was 
suppuration  in  the  left  loin  when  he  was  admitted  to  hospital, 
but  the  connection  between  that  condition  and  the  long 
history  of  recurring  pain  in  this  region  was  not  apparent. 
The  recurring  attacks  of  pain,  as  they  were  described  by  the 
patient,  strongly  pointed  to  renal  calculus ;  but  this  would 
not  give  rise  to  retronephric  suppuration.  And  retronephric 
it  evidently  was,  for  had  the  swelling  been  in  the  kidney  it 
would  have  been  palpable  bimanuaUy,  and  had  it  been 
perinephric  it  would  also  have  been  so,  while  in  both 
conditions  there  would  not  have  been  complete  absence  of 
pain  on  pressing  from  the  front.  One  of  my  surgical  col- 
leagues at  the  time  incised  the  loin  and  evacuated  a  large 
quantity  of  pus.  The  patient  made  an  uninterrupted  and 
complete  recovery. 

The  next  case  is  the  last  one  of  this  kind  I  had  in  my  male 
ward  in  the  Royal  Infirmary. 

Case  81. — J.  P.,  aged  46,  was  admitted  in  the  autumn  of 
1 918.  The  complaint  was  of  pain  in  the  right  loin,  which  had 
lasted  for  six  weeks.  The  pain  had  come  on  suddenly  on 
the  right  side  below  the  costal  margin.  He  had  been  confined 
to  bed  since  the  onset  of  pain.  The  pain  was  intermittent 
and  was  sharp  and  stabbing  in  character.  There  were  no 
urinary  symptoms.     On  examination  the  abdomen  moved 


PERINEPHRITIS  291 

freely  with  respiration.  Bimanual  palpation  of  the  right 
loin  revealed  a  hard  mass  projecting  forwards  towards  the 
anterior  abdominal  wall,  which  was  tender.  The  temperature 
was  raised,  and  the  pulse  accelerated.  The  diagnosis  was 
perirenal  suppuration.  The  patient  objected  at  first  to 
operation,  but  finally  consented  and  was  transferred  to 
Professor  Caird's  ward.  The  loin  was  incised,  the  pus 
evacuated,  and  the  cavity  scraped.  The  healing  was  very 
slow,  but  the  patient  made  a  good  recovery. 


CHAPTER   XXV 

RENAL   CALCULUS   AND   RENAL    COLIC 

Calculi  form  in  the  pelvis  or  calices  of  the  kidney  and  give 
rise  to  symptoms  which  will  be  presently  described.  The 
calculi  vary  considerably  in  composition,  being  formed  of  uric 
acid,  oxalates,  phosphates,  or  of  combinations  of  these.  Their 
mode  of  formation  and  the  conditions  determining  their 
formation  need  not  be  discussed  here,  but  it  is  to  be 
remembered  that  alterations  in  the  chemical  contents  of 
the  urine  are  determined  by  alterations  or  aberrations  of 
metabolism,  and  that  these  are  often  spoken  of  and  placed 
under  the  somewhat  vague  definition  of  a  "  gouty  "  or 
"  rheumatic  diathesis," 

Symptoms. — The  first  symptom  produced  by  renal 
calculus  is  pain.  The  pain  is  intermittent  and  paroxysmal 
and  is  known  as  renal  colic.  The  severity  of  the  pain  varies 
greatly,  but  may  reach  an  intensity  that  is  agonizing.  The 
paroxysm  which  comes  on  suddenly  may  as  suddenly  subside 
or  completely  cease.  The  pain  is  usually  referred  to  the 
kidney  region  in  the  loin  ;  it  may  be  referred  to  the  lateral 
region  of  the  abdomen,  to  the  hypochondrium  of  the  affected 
side,  to  the  umbilical  region,  or  along  the  course  of  the  ureter 
to  the  upper  part  of  the  thigh,  or  in  the  male  to  the  testicle. 
An  intense  paroxysm  may  be  the  first  symptom,  indicating 
the  presence  of  stone.  When  this  is  the  history  it  has  to  be 
assumed  that  the  forming  of  the  stone  gave  rise  to  no 
appreciable  symptom,  and  that  the  sudden  and  severe  pain 
is  the  result  of  the  stone  having  moved  to  the  mouth  of  the 
ureter,  A  large  calculus  may  be  fixed  in  a  calyx,  or  in  more 
than  one  without  causing  pain  ;    but  such  cases  are  rare, 

292 


RENAL   CALCULUS   AND   RENAL   COLIC      293 

More  commonly  the  stone  is  small  or  of  moderate  size  and 
lies  free  in  the  kidney  pelvis. 

Examination. — When  the  abdomen  is  examined  in- 
spection supplies  no  guidance.  On  palpation  there  is  not 
as  a  rule  much  surface  tenderness,  and  I  have  never  seen 
calculus  cause  the  diffuse  surface  hyperaesthesia  which  some 
other  abdominal  conditions  may  produce.  If  surface  tender- 
ness be  present  it  is  usually  present  in  the  loin.  When  the 
kidney  region  is  to  be  explored  by  deep  palpation  both  hands 
are  used — one  in  the  loin,  the  other  at  the  part  in  front 
corresponding  to  the  position  of  the  hand  in  the  loin.  It 
facilitates  the  examination  to  stand  on  the  side  which  is 
being  explored.  One  hand  is  pressed  slowly  but  firmly  and 
deeply  into  the  loin  in  its  upper  part,  remembering  that  the 
kidney  is  normally  under  cover  of  the  ribs  ;  the  other  hand 
is  applied  in  a  similar  fashion  in  front,  and  in  such  a  position 
that,  were  intervening  tissues  removed,  the  fingers  would 
meet.  By  this  method  of  procedure  the  lower  part  of  the 
kidney  may  be  felt,  and  as  soon  as  it  is  thus  felt  the  patient 
will  complain  of  pain.  If  the  hands  are  relaxed  the  pain 
ceases,  and  it  can  again  be  elicited  by  again  grasping  the 
organ.  The  degree  of  tenderness,  of  course,  varies :  it  is 
most  intense  if  the  examination  is  made  when  an  attack 
of  renal  colic  is  present ;  but  it  can  be  elicited  between  the 
attacks  of  colic,  and  when  without  pressure  no  pain  is 
experienced.  Along  with  the  tenderness  the  kidney  is  often 
enlarged. 

The  examination  of  the  urine  is  the  next  proceeding. 
There  may  be  a  definite  history  of  haematuria,  but  a  patient 
sometimes  speaks  of  the  urine  having  been  "  like  blood  " 
when  it  is  merely  high-coloured  from  concentration.  Often 
there  is  no  such  history.  There  may  be  a  definite  history 
of  having  passed  small  calculi  after  attacks  of  pain.  When 
blood  is  present  in  considerable  amount  it  may  be  recognized 
by  the  smoky  appearance  of  the  urine  as  seen  in  a  glass 
vessel ;  by  the  guaicum  and  ether  test ;  or  the  deposit 
may  on  microscopic  examination  be  found  to  contain 
hgemocytes.     When  the  amount  of  blood  present  is  thus 


294  THE   KIDNEY 

easy  of  demonstration  the  urine  will,  of  course,  be  found  to 
contain  albumin.  Blood  may,  however,  be  present  in  such 
small  quantit}'  that  its  presence  cannot  be  demonstrated 
by  any  of  these  methods.  It  is  then  necessary  to  have 
recourse  to  centrifuging  the  urine,  and  carefuUy  examining 
the  sediment  microscopically.  When  this  is  done  a  positive 
result  strengthens  the  diagnosis  of  calculus.  The  presence 
of  even  a  few  haemocytes  in  the  sediment  indicates  that  there 
has  been  sufficient  irritation  to  cause  bleeding.  Crystals, 
as  uric  acid  and  oxalates,  may  also  be  present.  Leucocytes, 
and  epithelial  cells  from  the  pelvis  of  the  kidney,  if  present, 
still  further  indicate  that  there  has  been  irritation  ;  even 
tube  casts  may  be  found.  The  urine  from  each  kidney  may 
be  obtained  by  the  separator  and  examined  separately. 
This  procedure  may  supply  valuable  indications  as  to  the 
condition  not  only  of  the  affected  kidney  but  of  its  fellow. 

Examination  by  X-rays  may  be  made  and  when  the 
result  is  positive  the  evidence  is  unimpeachable.  On  the 
other  hand,  if  the  evidence  is  negative  it  is  unfortunately 
of  no  value,  for  it  does  not  disprove  the  presence  of  a  calculus. 
^Diagnosis  of  renal  calculus  is  thus  determined  by  the 
occurrence  of  paroxysms  of  pain  referred  mainly  to  the  region 
of  the  affected  organ,  by  eliciting  tenderness  in  the  organ 
by  palpation,  and  by  the  condition  of  the  urine. 

In  the  great  majority  of  cases  there  is  no  doubt  about  the 
diagnosis.  The  situation  of  the  pain  and  the  result  of 
bimanual  examination  of  the  kidney  region  are  sufficient  to 
warrant  the  diagnosis.  If  blood  be  present  in  the  urine  the 
diagnosis  is  established.  Here  again  the  supposed  difficulty 
in  diagnosis  is  the  result  of  vague  notions  about  abdominal 
pains.  A  renal  cohc  could  hardly  be  mistaken  for  intestinal 
colic.  Somewhat  similar  pain  might  be  caused  by  a  perforated 
duodenal  ulcer,  but  the  collapse  in  that  case  is  more  sudden 
and  more  pronounced,  and  there  is  usually  diffuse  surface 
hyperaesthesia.  Renal  colic  might  also  be  mistaken  for 
gall-stone  colic,  but  here  the  seat  of  tenderness  is  in  the  gall- 
bladder region  and  not  deep  in  the  loin.  There  are  no  other 
painful  conditions  with  which  it  can  be  reasonably  confused. 


RENAL   CALCULUS   AND   RENAL   COLIC      295 

The  further  history  depends  on  the  size  and  the  character 
of  the  stone,  and  necessarily  varies  very  greatly.  If  the 
stone  is  large,  it  cannot  pass  into  and  along  the  ureter ;  it 
remains  in  the  pelvis  and  its  position  varies  with  bodily 
movements  and  posture.  There  are  recurring  attacks  of 
severe  colic.  These,  as  has  already  been  stated,  are  due  to 
the  presence  of  the  stone  at  the  mouth  of  the  ureter,  where 
it  is  probably  grasped,  the  involuntary  muscle  spasm  causing 
pain  ;  while  the  retention  of  urine  in,  and  the  consequent 
dilatation  of,  the  pelvis  becomes  a  further  factor  in  pain 
production.  As  the  result  of  these  recurring  phenomena  the 
kidney  enlarges  and  is  readily  palpated,  and  a  considerable 
degree  of  pain  is  caused  by  manipulation.  At  this  stage  also 
there  is  no  reasonable  doubt  as  to  the  diagnosis.  An  X-ray 
examination  may  or  may  not  confirm  the  diagnosis.  Stone 
of  hard  consistence  is  shown,  while  other  stones  do  not  show. 
The  result  is  that  only  a  positive  shadow  is  of  confirmatory 
value,  while  if  a  negative  observation  is  accepted  a  grievous 
blunder  may  be  made,  grievous  both  to  the  patient  and  to 
the  physician.  Considerable  irritation  may  be  set  up  in  the 
pelvis  by  the  stone  leading  to  the  presence  of  pus  and  blood 
in  the  urine.  In  all  such  cases  the  only  cure  is  surgical 
interposition.  When  the  diagnosis  is  made  operation  ought 
to  be  unequivocally  advised.  If  this  advice  is  not  acted 
upon,  life  becomes  embarrassed  and  its  activities  greatly 
restricted. 

Case  82. — Some  years  ago  I  saw  a  gentleman,  who  was 
passing  through  Edinburgh,  on  account  of  hsematuria  with 
pain  in  the  right  loin.  I  was  informed  that  he  had  suffered 
from  attacks  of  this  description  for  years,  and  that  he  had  to 
be  very  careful  as  to  the  amount  and  kind  of  exercise  he 
took,  as  any  little  excess  even  of  walking  brought  on  an 
attack.  There  was  a  large  amount  of  blood  mixed  with  the 
urine  ;  the  right  kidney  was  large  and  tender.  He  had  been 
X-rayed  and  assured  that  there  was  no  stone  in  the  kidney. 
I  expressed  the  opinion  that  there  was,  and  explained  that  a 
negative  X-ray  examination  could  not  be  accepted,  as  some 
kinds  of  stone  did  not  show.     I  strongly  advised  operation. 


296  THE   KIDNEY 

When  he  returned  to  his  home  south  of  the  Border  he  was 
again  X-rayed  and  assured  there  was  no  stone.  I  adhered 
to  my  view,  but  could  do  no  more,  however  much  one 
regretted  that  an  otherwise  hale  man,  occupying  an  influential 
position,  should  continue  to  be  hindered  and  handicapped 
at  every  turn  by  a  condition  which  was  susceptible  of  suc- 
cessful surgical  interposition  even  if  it  meant  the  removal 
of  the  organ. 

This  class  of  case  is  fortunately  not  now  common  in  the 
experience  of  the  physician.  On  the  other  hand,  the  less 
severe  cases  are  fairly  common. 

Case  83. — A  medical  man,  aged  28,  had  suffered  for  some 
time  from  pain  in  the  loins  with  a  sense  of  weariness.  The 
urine  contained  oxalates  and  he  had  passed  some  very  small 
calculi  without  pain.  Regulation  of  diet,  particularly  a 
reduction  in  the  amount  of  flesh  he  had  been  eating  and  an 
increase  in  carbohydrate  food,  soon  led  to  the  relief  of 
symptoms  and  the  disappearance  of  oxalates  from  the  urine. 

Reference  has  been  made  to  pain  and  to  tenderness  in 
the  renal  region  with  perhaps  some  blood  in  the  urine.  If 
the  stone  is  small  enough  to  get  into  the  ureter,  severe  pain 
may  be  caused  by  its  propulsion  along  the  ureter,  the  pain 
following  the  course  of  the  ureter  downwards  towards  the 
groin,  until  the  stone  escapes  into  the  bladder,  such  escape 
giving  immediate  relief.  From  the  bladder  the  stone  may 
be  passed  by  way  of  the  urethra  painlessly,  or  with  more  or 
less  pain,  according  to  the  size,  shape,  and  character  of  the 
stone.  It  may  be  arrested  for  some  time  at  the  lower  end 
of  the  ureter,  when,  as  will  be  shown  in  the  following  cases, 
the  question  of  diagnosis  may  present  some  difficulty. 

Case  84. — A  clergyman,  well  up  in  middle  life  and  hving 
in  a  country  district  far  from  a  medical  man,  was  seized  at 
night  with  pain  in  the  abdomen  and  vomiting.  The 
temperature  was  raised  two  or  three  degrees.  Suggestions 
of  indiscretion  in  diet  were  offered  in  explanation  of  the 
symptoms.  The  pain  began  in  the  right  loin,  and  extended 
downwards  towards  the  groin  ;  and  there  was  a  history  of 
attacks  of  "  gravel."     On  examination  of  the  abdomen  there 


RENAL   CALCULUS  AND   RENAL   COLIC       297 

was  tenderness  in  the  right  ihac  region,  and  the  anxious 
question  arose  as  to  whether  the  case  was  an  acute  appendix 
or  a  renal  calculus.  The  history  suggested  the  latter,  and 
as  the  tender  area  was  small,  and  it  was  known  that  pain 
in  this  patient  alwa3^s  led  to  a  rise  of  temperature,  that 
presumption  was  strengthened.  A  small  injection  of 
morphine  and  atropine  relieved  the  pain  and  the  patient  had 
a  good  night.  In  the  morning  there  was  no  pain  or  tender- 
ness, and  the  temperature  was  normal.  After  a  day  or  two 
in  bed  he  was  able  to  be  up.  A  day  or  two  later  he  showed 
me  a  couple  of  small  calculi,  smaller  than  grape  seeds,  which 
had  passed  by  the  urethra  without  pain. 

Case  85. — ^This  patient  was  a  young  man,  who  had  suffered 
all  night  from  severe  pain  in  the  abdomen,  for  which  he  had 
been  diligently  treated  by  hot  applications  and  enemata,  on 
the  advice  of  his  medical  attendant.  On  asking  him  as  to 
where  the  pain  began  he  referred  it  to  the  left  loin,  and  stated 
that  it  had  extended  down  the  left  side  of  the  abdomen.  The 
pain  was  constant  with  severe  exacerbations.  There  was 
tenderness  in  the  left  iliac  region  and  nowhere  else.  The  case 
seemed  to  be  one  of  renal  colic,  in  which  the  stone  had  reached 
the  lower  end  of  the  ureter  ;  but  again  the  question  was  raised 
whether  it  might  not  be  an  appendix  stretching  across  to  the 
left  iliac  region.  Belladonna  in  full  doses  was  recommended, 
and  it  was  arranged  that  the  patient  should  be  sent  to  the 
Royal  Infirmary  to  the  ward  of  a  surgical  colleague.  By  the 
time  he  arrived  there  the  pain  was  much  less,  but  there  was 
stiU  local  tenderness,  and  the  surgeon  had  to  be  persuaded 
to  postpone  operation.  The  patient  rapidly  improved 
further,  so  that  all  thought  of  operation  was  abandoned, 
and  he  was  discharged.  In  a  few  days  the  patient  brought 
a  smooth  calculus,  smaller  than  a  coffee  bean,  which  had  been 
passed  by  the  urethra  with  trifling  inconvenience. 

Case  86. — M.  W.,  aged  30,  was  admitted  to  my  male 
ward.  He  complained  of  pain  in  the  right  lower  segment  of 
the  abdomen.  The  history  was  that  some  time  before 
admission  he  was  believed  to  have  renal  calculus,  and  that 
operation  for  removal  had  been  performed,  but  no  stone  was 


298  THE  KIDNEY 

found.  There  was  a  good  lumbar  scar.  On  palpation  of  the 
abdomen  there  was  a  limitied  area  of  tenderness  on  pressure 
at  the  lower  part  of  the  csecal  region.  The  peculiarity  of 
this  area  of  pain  on  pressure  was  that  movement  of  the  thigh 
on  the  trunk  or  of  the  trunk  alone  caused  pain  at  the  same 
point.  It  was  the  pain  on  movement  that  sent  him  into 
hospital  as  it  prevented  him  working.  The  case  thus  presented 
a  history  of  diagnosis  of  renal  calculus,  and  of  a  disappointing 
operation  in  skilful  hands.  The  localitj^  of  the  pain  and 
tenderness,  when  we  saw  him,  definitely  suggested  appendix, 
with  this  reservation,  however,  that  one  had  never  seen  a 
chronic  appendix  produce  pain  on  movement.  A  surgical 
colleague  saw  the  case,  and  his  opinion  was  that  the  tender 
area  was  caused  by  the  appendix.  It  was  quite  clear  that 
the  cause,  whatever  it  was,  of  this  unusual  type  of  pain  had 
to  be  removed.  At  the  operation  the  appendix  was  shown 
to  be  one  of  the  S-shaped  appendices  which  are  prone  to  give 
trouble,  and  it  was  removed  After  this  the  region  was  further 
explored,  especially  the  ureter,  with  the  result  that  an  ovoid 
calculus  about  the  size  of  a  cherry  stone  was  removed.  The 
stone,  of  course,  explained  the  pain  and  its  unusual  character. 
The  patient  made  an  excellent  recovery  and  was  cured. 

The  following  case  illustrates  another  aspect  of  renal 
calculus. 

Case  87. — Mrs.  S.,  aged  50,  had  been  subject  for  a  few 
years  to  attacks  of  "  chill  in  the  stomach  and  inflammation." 
These  attacks  were  characterized  by  abdominal  pain,  the 
pain  being  referred  to  about  the  centre  of  the  abdomen. 
Five  months  before  I  saw  her  she  had  a  severe  attack  which 
confined  her  to  bed ;  after  a  time  she  got  up,  but  this  was 
followed  by  a  return  of  the  pain.  The  doctor  examined 
the  urine  at  this  time  and  found  blood  in  it.  On  more  careful 
inquiry  it  was  ascertained  that  the  pain  was  situated  on  the 
right  side  of  the  abdomen,  going  as  far  down  as  the  groin. 
During  paroxysms  of  pain  she  vomited.  She  was  definite 
in  the  statement  that  pain,  vomiting,  and  the  amount  of 
blood  in  the  urine  were  in  proportion  one  to  the  other.  For 
six  weeks  there  had  been  no  pain,  and  blood  had  gradually 


RENAL   CALCULUS  AND   RENAL   COLIC      299 

disappeared  from  the  urine.  On  examination  of  the  abdomen 
the  kidney  was  not  palpable,  and  therefore  not  enlarged  ; 
but  there  was  slight  tenderness  on  bimanual  deep  pressure 
up  under  the  right  ribs.  Ihe  urine  contained  nothing 
abnormal  save  that  it  threw  down  urates  on  coohng.  In 
other  respects  the  patient's  health  was  satisfactory.  The 
bowels  acted  easily  and  daily  ;  there  were  no  symptoms  of 
indigestion  ;  and  the  circulation  was  satisfactory.  The 
patient  was,  however,  taking  too  little  fluid.  The  opinion 
I  expressed  was  that  the  calculus  had  passed  along  the 
ureter,  and  might  have  been  passed  from  the  bladder  without 
the  patient  noticing  it.  I  suggested  that  she  should  be 
instructed  to  take  more  fluid,  and  that  it  might  be  taken  as 
lithia  water.  For  nine  months  there  has  been  no  recur- 
rence of  calculus  symptoms. 

Case  88. — Two  Uric  Acid  Calculi  removed  from  Kidney. — 
James  H.,  aged  29  years,  was  admitted  into  the  Royal 
Infirmary,  Edinburgh,  with  a  history  of  having  seen 
several  doctors  and  of  having  been  in  at  least  two 
other  hospitals  for  symptoms  corresponding  to  those  which 
led  to  his  being  sent  to  the  Infirmary.  The  history  was 
that  for  the  preceding  three  months  he  had  had  severe 
attacks  of  pain  in  the  abdomen ;  the  right  intermediate 
third  of  the  abdomen  being  the  position  to  which  the  pain 
was  referred.  The  paroxysms  of  pain  came  on  suddenly  and 
at  any  time.  He  had  been  seized  in  the  street,  he  had  been 
seized  when  at  work  so  severely  that  he  had  had  to  go  home. 
His  wife  stated  that  the  pain  might  last  for  twenty-four  hours 
or  longer,  and  that  his  cries  could  be  heard  outside  the  house. 
When  the  pain  was  severe  he  often  vomited.  For  three 
months  he  had  had  an  attack  of  pain  almost  every  week. 
On  questioning  him  closely  as  to  the  beginning  of  his  attacks, 
it  appeared  that  he  had  had  his  first  attack  many  years 
before,  but  he  could  not  give  a  date.  The  last  three  months, 
however,  covered  the  period  during  which  they  had  been  a 
serious  factor  in  his  life.  The  pain  neither  went  down  towards 
the  thigh  nor  up  into  the  chest,  but  it  sometimes  went  round 
into  the  loin.     The  pain  went  away  as  suddenly  as  it  came 


300  THE   KIDNEY 

on.  Inquiring  as  to  the  effect  of  taking  food,  he  thought 
that  a  heavy  dinner  was  apt  to  bring  on  an  attack,  whilst 
light  food  had  no  bad  effect.  He  had  no  pain  when  passing 
water,  and  he  was  not'aware  of  ever  passing  blood.  When  the 
pain  was  present  he  found  that  lying  on  the  right  side,  or 
still  better  resting  on  his  elbows  and  knees,  gave  relief.  He 
had  been  given  morphia  hypodermically  for  the  relief  of  the 
pain.  He  had  been  told  that  he  was  suffering  from  "  neuralgia 
of  the  kidney,"  but  he  definitely  asserted  that  it  had  not  been 
suggested  to  him  that  he  had  a  stone  in  the  kidney.  Dr. 
Carruthers,  who  had  sent  him  to  the  Infirmary,  had,  however, 
been  of  opinion  that  he  was  suffering  from  renal  calculus, 
and  it  was  this  opinion  which  led  him  to  send  the  patient  to 
the  Infirmary. 

Condition  on  Admission. — He  was  a  well-nourished  man 
with  a  somewhat  florid  complexion. 

Examination  of  Abdomen. — ^There  was  nothing  abnormal 
to  note  on  inspection  of  the  abdomen.  On  palpation  the 
liver  edge  was  felt,  but  there  was  no  tenderness  over  it  nor 
over  the  position  of  the  gall-bladder  even  on  deep  palpation. 
The  liver  was  not  enlarged.  The  caecal  region  was  then  care- 
fully explored  and  no  tenderness  was  elicited  in  that  region 
on  deep  palpation.  Hepatic  colic  or  appendix  colic  were 
therefore  excluded.  The  region  of  the  right  kidney  was  then 
examined  bimanually,  and  soon  after  I  began  to  approximate 
the  two  hands  he  winced  and  complained  of  pain.  The 
hand  in  the  loin  specially  brought  out  the  pain  when  it 
was  pressed  deeply.  The  kidney  was  felt  between  the 
two  sets  of  fingers,  and  a  moderate  degree  of  pressure  made 
him  make  a  very  wry  face.  The  urine  contained  some  red 
blood  corpuscles,  some  pus  cells,  hyaline  casts,  and  oxa- 
lates. Examination  by  X-rays  was  negative.  The  patient 
was  transferred  to  the  surgical  side  of  the  hospital  with  the 
diagnosis  of  renal  calculus  on  the  right  side.  The  urine  from 
the  two  kidneys  was  separated,  when  it  was  found  that  there 
was  less  urine  coming  from  the  left  kidney  than  from  the 
right  one  and  that  it  was  from  the  left  that  the  blood  was 
coming.     In  view  of  these  facts  the  surgeon  under  whose 


RENAL  CALCULUS   AND   RENAL   COLIC      301 

care  he  was  did  not  think  him  a  favonrablc  or  even  a  suitable 
case  for  operation,  and  he  was  sent  out.  He  returned  shortly, 
beseeching  that  he  should  be  operated  on  as  the  pain  was 
becoming  worse  and  was  quite  unbearable.  He  was 
accordingly  operated  on  and  two  calculi  were  removed  from 
the  pelvis  of  the  right  kidney.  He  got  on  satisfactorily  for 
a  day  or  two,  but  he  became  drowsy  and  died  evidently  of 
uraemic  coma.  The  lesson  to  be  learnt  from  this  case  is  the 
necessity  of  early  operation.  Had  the  diagnosis  been  made 
three  months  earlier  the  result  of  operation  would  probably 
have  been  the  reverse  of  what  it  unfortunately  was. 

Remarks.  —  The  foregoing  cases  illustrate  the  clinical 
phenomena  of  renal  colic  and  the  questions  to  which  it  may 
give  rise.  The  main  object  of  this  section  has  been  to  show 
that  renal  colic  is  readily  diagnosed  once  vague  notions 
regarding  abdominal  phenomena  are  put  aside,  and  the  fact 
is  accepted  that  the  right  and  the  left  loin  belong  to  the 
kidney  ;  and  that,  when  the  diagnosis  is  difficult,  it  has  to  be 
proved  that  the  symptoms  are  not  renal.  Pain  and  tender- 
ness in  this  region  are  renal  in  origin  in  the  vast  majority  of 
cases  ;  and  in  the  minority  of  difficult  cases  it  has  to  be 
proved  that  the  pain  and  tenderness  are  not  renal.  This  point 
is  further  illustrated  in  the  following  chapter.  It  has  also 
been  shown  that  a  small  stone  may  give  rise  to  pain  beginning 
in  the  loin  which  extends  along  the  line  of  the  ureter  as  the 
stone  passes,  and  that  there  is  an  area  of  tenderness  at  the 
point  where  the  stone  is  arrested. 


CHAPTER  XXVI 

ENLARGEMENT   OF  THE   KIDNEYS 

In  this  chapter  the  conditions  dealt  with  are  hydronephrosis, 
pyonephrosis,  and  mahgnant  neoplasm. 

I.  Hydronephrosis 

Hydronephrosis  means  distension  of  the  pelvis  and 
calices  of  the  kidney  by  retained  urine,  the  result  of  obstruc- 
tion to  its  escape  by  way  of  the  ureter.  It  leads  to  pressure 
upon  and  destruction  of  the  essential  tissue  of  the  organ ; 
and  to  enlargement  of  the  organ  in  different  degrees.  In 
advanced  cases  the  kidney  is  so  completely  destroyed  that 
it  no  longer  performs  its  excretory  functions.  The  main 
causes  of  obstruction  are  renal  calculus,  permanently  or 
intermittently  blocking  the  outlet ;  and  freely  movable  or 
floating  kidney.  In  the  latter  case  retention  is  caused  by 
such  an  alteration  in  the  position  of  the  axis  of  the  organ  to 
the  ureter  that  sufficient  kinking  or  twisting  of  the  ureter 
occurs  to  prevent  outflow.  This  also  may  be  intermittent. 
When  kinking  occurs  the  urine  is  retained,  and  causes 
much  pain.  It  leads  to  much  distension  and  enlargement, 
which  lessens  when  the  kink  is  removed  and  the  retained 
urine  escapes.  By  repetition  of  this  process  not  only  does 
enlargement  result  but  the  entire  kidney  structure  is  practi- 
cally destroyed. '  Many  years  ago  I  saw  a  typical  case  of 
this  kind  on  the  right  side  in  a  woman  who  declined  operative 
interference.  It  was  at  a  time  when  abdominal  surgery  had 
not  attained  its  present  excellence,  and  operation  was  not 
pressed  as  it  would  be  to-day. 

302 


ENLARGEMENT   OF  THE   KIDNEYS  303 

Lesions  in  the  pelvis,  particularly  in  women,  may 
involve  the  lower  end  of  the  ureter  so  completely  that  hydro- 
nephrosis and  great  distension  and  thickening  of  the  affected 
ureter  result.  I  have  seen  both  kidneys  become  progressively 
involved  in  this  way. 

Diagnosis. — Diagnosis  is  determined,  firstly  by  the  history, 
although  this  may  be  misleading ;  secondly,  by  palpation, 
the  resilience  of  the  mass  being  that  of  a  cyst  and  not  of  a 
soUd  body ;  and  thirdly,  by  collecting  separately  whatever 
fluid  escapes  from  the  ureters. 

The  following  case  is  an  example  of  a  hydronephrotic 
cystic  kidney,  the  cause  of  which  seemed  to  have  been 
mobiUty.  The  case  was  examined  and  fully  discussed  with 
the  students  attending  my  clinic,  and  the  hne  of  argument 
is  reproduced  as  illustrating  the  method  employed  in  teaching. 

Case  89. — T.  L.,  aged  33,  was  admitted  on  the  23rd 
August,  1918,  to  the  Royal  Infirmary. 

History. — The  patient  was  in  the  Reserve  when  the  War 
broke  out  in  August,  1914.  He  was  called  to  the  colours 
and  sent  to  France.  He  was  soon  on  the  sick  hst,  was 
invaUded  home,  and  discharged  in  January,  1915,  after  being 
two  and  a  half  months  in  hospital.  He  did  light  work  for  a 
year,  and  then  worked  for  two  years  as  a  labourer.  Two 
years  before  admission  to  my  ward  he  was  in  a  surgical  ward 
for  a  few  days  for  observation.  A  year  later  he  was  admitted 
to  a  military  hospital,  where  he  was  X-rayed.  He  under- 
stood that  nothing  was  found ;  in  this  hospital,  however, 
he  learnt  that  there  was  blood  in  the  urine.  For  a  year  before 
admission  to  my  ward  he  had  worked  as  a  dock  labourer. 
He  had  suffered  from  pain  in  the  abdomen  since  he  had 
returned  from  France.  The  pain  was  on  the  left  side  and 
went  round  to  the  loin.  In  addition  to  a  constant  dull 
aching  in  this  region,  he  had  severe  attacks  of  pain,  the  pain 
being  worse  in  front,  with  a  feeling  of  tightness  in  the  loin. 
He  had  had  about  three  of  these  attacks  each  year,  since  the 
end  of  1914.  Each  attack  lasted  about  a  week.  He 
associated  these  attacks  with  constipation,  for  they  had 
been  relieved  by  getting  the  bowels  freely  moved.     The 


304  THE   KIDNEY 

attack  for  which  he  was  admitted  to  my  ward  had  lasted  for 
a  week. 

Examination.  —  He  complained  of  a  dull  aching  pain 
with  a  feeling  of  tightness  referred  to  the  left  loin.  There 
was  blood  in  the  urine,  sufficient  in  quantity  to  be  recognized 
by  the  unaided  eye.  In  the  course  of  a  few  days  the  urine 
became  normal.  On  palpation  of  the  abdomen  there  was 
readily  felt  an  abnormal  mass,  which  extended  from  the  rib 
margin  to  the  iliac  fossa  on  the  left  side.  It  did  not  cause 
any  projection  or  bulging  of  the  abdominal  wall  ;  it  was 
longer  than  it  was  broad  ;  the  surface  was  smooth  and  slightly 
lobulated ;  it  was  readily  felt  bimanually  with  one  hand  in 
the  loin ;  the  left  loin  was  fuller  and  much  more  resistant 
than  the  right ;  there  was  no  tenderness  ;  there  was  dullness 
on  percussion.  The  tympanitic  note  of  the  stomach  fundus 
was  present  in  the  usual  position.  There  was  no  increase  in 
the  area  of  splenic  dullness  such  as  is  present  when  that 
organ  is  enlarged  and  projects  beyond  the  costal  margin. 

Remarks  on  Diagnosis. — The  points  in  this  case  were 
(i)  the  local  pain  directing  attention  to  the  abdomen,  and  to 
the  left  half  of  it,  including  the  flank  and  loin ;  (2)  the  palpable 
mass  in  this  region  ;  (3)  the  temporary  presence  of  blood  in 
the  urine ;  (4)  the  recurrence  of  attacks  of  pain  associated 
with  constipation  relieved  by  free  colon  evacuation. 

The  first  problem  this  case  presents  is  :  What  is  this 
mass  ?  And  I  ask  you  to  realize  that  the  number  of  possi- 
bilities is  limited  ;  you  must  not  allow  your  brains  to  be 
rattled  with  the  idea  that  the  field  of  possibilities  is  large, 
vague,  and  indefinite.  We  are  dealing  with  a  human 
abdomen,  a  cavity  of  the  body  of  which  we  know  the  anatomy 
and  understand  much  of  its  pathology.  For  clinical  purposes 
I  submit  to  you  that  a  mass  like  this  in  this  position  is 
pathological ;  and  that  when  you  begin  to  consider  what 
part  or  organ  is  involved  you  are  confined  to  spleen,  splenic 
flexure  of  colon,  and  kidney.  Take  these  in  order.  When 
the  spleen  is  enlarged  the  normal  area  of  splenic  dull- 
ness enlarges  upwards,  forwards,  and  downwards.  There 
is   no    extension    of    dullness    upwards    and  forwards    in 


ENLARGEMENT   OF   THE   KIDNEYS         305 

this  case.  The  area  of  stomach  fundus  tympanicity  is 
present,  in  its  normal  position.  With  these  facts  before  us 
it  may  be  confidently  asserted  that  the  mass  is  not  an 
enlarged  spleen.  Take  next  the  splenic  flexure  of  the  colon. 
This  is  one  of  the  important  parts  of  the  colon.  It  is  firmly 
fixed  up  in  this  region,  and  it  is  one  of  the  points  where 
malignant  neoplasm  occurs.  Mahgnant  neoplasm  here  may 
grow  to  a  considerable  size  before  it  gives  rise  to  complete 
intestinal  obstruction.  When  such  a  neoplasm  occurs  and 
attains  much  size  it  remains  higher  in  position  than  this  mass 
has  done,  it  projects  more  forward  and  towards  the  mesial 
plane,  it  can  be  palpated  under  the  costal  margin,  and  if 
big  enough  to  be  palpable  it  will  give  a  dull  percussion 
sound  over  the  lower  ribs.  It  is  not,  however,  common  to 
have  a  neoplasm  attaining  such  dimensions  in  this  region, 
but  it  may  presumably  be  met  with. 

\'\nien  neoplasm  occurs  here  there  is  a  history  available 
of  recurring  symptoms  of  pronounced  constipation,  amount- 
ing at  times  to  temporary  obstruction,  and  overcome  with 
difficulty.  These  sjmiptoms  not  being  present,  we  pass  to  the 
next  possibility,  namely,  kidney.  The  position  of  the  mass 
suggests  most  readily  that  it  is  an  enlarged  kidney,  enlarged 
in  length  and  in  circumference  ;  it  projects  downwards  much 
beyond  its  normal  limit ;  it  fiUs  up  the  loin,  and  examined 
bimanuaUy  it  is  found  to  be  several  times  larger  than  a 
normal  kidney.  In  text-books  you  wiU  find  it  stated  that 
a  mass  like  this  will  give  a  tympanitic  note  on  percussing  it 
in  front  if  it  is  kidney  as  the  descending  colon  hes  in  front 
of  it.  There  is  no  such  tympanitic  note  in  this  case.  Let 
me  impress  upon  you  that  you  have  to  apply  common  sense 
to  the  examination  of  the  abdomen.  The  absence  of  a 
tympanitic  note  in  front  of  this  mass  cannot  be  taken  as 
evidence  that  the  colon  is  not  in  front  of  it,  it  only  means  that 
the  descending  colon  is  not  fuU  of  gas.  Without  gas  or  air 
in  it  no  part  of  the  intestine  gives  a  t3aiipanitic  note,  so  this 
test  is  not  rehable.  But  this  point  can  be  carried  even 
further  :  if  this  is  a  kidney,  as  we  beHeve  it  to  be,  the  kidney 
enlarging  from  behind  the  colon  will  press  upon  and  compress 

20 


3o6  THE   KIDNEY 

it,  so  as  not  only  to  prevent  air  or  gas  accumulating,  but  to 
lead  to  difficulty  in  the  passage  of  more  solid  colon  contents. 
The  empty  and  contracted  colon  can  in  this  patient  be  felt 
running  from  above  dowTiwards  in  front  of  the  enlarged 
kidney.     This  I  submit  is  the  explanation  of  the  special 
attacks  of  pain,  accompanied  by  constipation,  and  reheved 
by  the  emptjdng  of  the  colon,  referred  to  in  the  history  of 
the  symptoms  ehcited  from  the  patient.     This  leads  to  the 
next   question  :    ^^'^lat   change  has  the  kidney  undergone 
which  has  led  to  the  enlargement  ?     I  again  impress  upon 
you  the  necessity  of  recalhng  and  applying  your  knowledge 
of  pathology,  and  passing  in  mental  review  the  common 
causes  of  enlargement  of  this  organ  :    they  are  neoplasm, 
hydronephrosis,  pyonephrosis,  and  congenital  cj^stic  kidney. 
Take  these  in  order.     First,  neoplasm  ;    neoplasm  in  this 
organ   may  for   cUnical   purposes   be   regarded   as   always 
malignant,  either  sarcoma  or  carcinoma.     With  a  history  of 
four  years'  duration,  the  absence  of  cachexia,  and  the  mass  not 
larger  than  it  is,  malignant  growth  may  be  set  aside.     Tuber- 
culous disease  does  not  lead  to  such  enlargement  as  is  present 
here.     The  patient  shows  no  constitutional  reaction,   and 
the  urine  does  not  contain  pus.     This  possibility  may  there- 
fore be  also  put  aside.     There  remains  for  consideration 
cystic  kidney,  the  result  either  of  hydronephrosis,  of  p3^o- 
nephrosis,  or  of  increase  in  size   of  a  congenitally  cystic 
kidney.     The    last    mentioned   is    a    very   rare    condition, 
and  usually  affects  both  organs  ;   but  in  this  patient  there  is 
no  e\ddence  of  enlargement  of  the  right  kidney.     Hydro- 
nephrotic  cystic  kidney  may  result  from  a  calculus  in  the 
pelvis  blocking  the  ureter  from  time  to  time,  but  the  pain 
has  never  been  of  the  description  caused  by  such  occur- 
rences :   hydronephrosis,  however,  occurs  in  movable  kidney 
when  a  change  in  the  position  of  the  organ  leads  to  kinking 
of  the  ureter  with  consequent  retention  of  the  renal  excretion 
in  the  pelvis  and   calices.      Of  the  pre-existence   of  such 
mobility  in  this  patient  we  have  no  definite  knowledge.     The 
intermittent  presence  of  blood  in  the  urine  maj^  occur  in 
both  conditions  ;   but  a  history  of  renal  calculus  is  entirely 


ENLARGEMENT   OF  THE   KIDNEYS  307 

wanting,  so  we  reach  by  the  method  of  exclusion  the  diagnosis 
of  hydronephrosis  due  probably  to  mobiUty. 

Treatment. — What  can  be  done  for  the  patient  ?  is  a 
question  which  need  not  be  answered  until  our  argument 
has  been  checked  by  all  the  means  at  our  disposal.  He  will 
be  X-rayed  after  bismuth  with  the  object  of  showing  the 
condition  of  the  splenic  flexure,  and  perhaps  of  the  descending 
colon  in  relation  to  the  kidney.  The  functional  activity  of 
both  kidneys  will  be  investigated  ;  the  object  being  to 
determine  whether  the  left  kidney  is  worth  preserving. 

These  examinations  were  duly  made  by  Dr.  Hope  Fowler 
in  the  Electrical  Department  and  by  Professor  Caird  on  the 
surgical  side.  The  X-ray  photograph  showed  the  bismuth 
piled  up  in  and  on  either  side  of  the  splenic  flexure,  and 
none  in  the  descending  colon,  while  later  it  passed  to  the 
rectum.  The  explanation  of  the  severe  attacks  of  pain 
with  constipation  was  thus  confirmed.  Professor  Caird 
found  that  there  was  practically  no  urine  coming  from  the 
left  ureter.  This  being  so,  there  was  no  room  for  difference 
of  opinion  as  to  the  treatment  to  be  followed,  if  the  patient 
wanted  to  be  cured  of  the  pain  and  discomfort  which  were 
interfering  with  his  work.  The  operation  was  performed 
on  the  19th  September,  and  the  kidney,  a  hydronephrotic 
cystic  one,  was  removed.  The  cause  of  the  hydronephrosis 
was  not  ascertained.  The  patient  made  an  excellent 
recovery. 

2.  Pyonephrosis 

This  term  means  distension  of  the  pelvis  and  calices  of 
the  kidney  with  pus  causing  enlargement  of  the  organ  and 
destruction  of  the  kidney  tissue.  The  following  is  the  most 
striking  case  met  ^vith  in  my  experience,  as  presenting 
unusual  difficulties  in  diagnosis. 

Case  90. — The  patient,  a  boy  of  12,  was  sent  to  my  ward 
by  the  family  medical  attendant  because  of  an  abdominal 
tumour  which  had  lasted  for  months  and  was  enlarging. 
The  boy  did  not  look  ill,  and  he  had  no  pain.  There  was  no 
rise  of  temperature  and  pulse  and  respirations  were  quiet. 


3o8  THE  KIDNEY 

On  examination  a  very  large  mass  was  visible  on  the  left 
side  of  the  abdomen ;  on  palpation  it  was  hard  and  resistant ; 
it  extended  from  the  costal  margin  to  the  iUac  fossa  ;  it 
seemed  to  occupy  about  one-third  or  so  of  the  abdominal 
cavity ;  it  was  not  tender  ;  it  bulged  the  left  loin  and  was 
palpable  bimanuaUy ;  its  surface  was  smooth  with  project- 
ing parts  ;  its  anterior  and  inferior  margins  were  definite 
and  sharp.  On  percussion  it  was  dull ;  but  the  dullness  did 
not  extend  upwards  under  the  ribs  as  the  dullness  of  a  large 
spleen  extends.  On  examination  of  the  urine  nothing 
abnormal  was  found.  A  blood  count  gave  12,000  leucocytes, 
mainly  polymorphs. 

There  was  no  doubt  that  this  great  mass  was  renal. 
The  position  of  its  upper  Umit  negatived  any  idea  of  splenic 
origin.     If  then  it  was  a  renal  tumour  it  was  difficult  to  think 
of  any  lesion  but  sarcoma.     In  any  case  surgical  intervention 
was  obviously  called  for.     My  surgical  colleague  Professor 
Caird  saw  the  boy  with  me  and  he  agreed  in  thinking  it  a 
renal  tumour  and  almost  certainly  sarcoma.     The  parents 
were  willing  that  the  operation  should  be  done,  although  we 
did  not  hold  out  much  hope  that  cure  could  be  effected,  in 
view  of  the  size  of  the  mass  to  be  removed  and  of  what  we 
believed  its  character  to  be.     At  the  operation  it  was  found 
to  be  a  great  pyonephrosis.     The  little  fellow  succumbed 
to   the   shock   of   the   operation.     Had   the   patient   been 
operated  on  earlier  the  shock-element  would  have  been  less. 
I  learned  later  that  the  mass  had  been  earlier  diagnosed  as 
glandular  and  had  been  treated  by  intravenous  medication. 
Remarks.  —  Comment   here    is    confined   to    the    extra- 
ordinary absence  of  symptoms  in  face  of  the  increasing  size 
of  the  huge  abscess  sac.     The  leucocytosis  present  was  not 
more  than  might  have  been  caused  as  the  result  of  irritative 
action  round  a  malignant  growth.     And  this  leucocytosis 
may  possibly  have  led  to  the  earher  diagnosis  of  enlarged 
glands.     Had  pyonephrosis   even   been  suspected  the  sac 
might  have  been  tapped  and  emptied,  thereby  lessening  the 
shock  of  later  removal. 

The  following  case  occurred  many  years  ago  and  before 


ENLARGEMENT  OF  THE   KIDNEYS  309 

surgeons  opened  the  abdomen  with  the  freedom  from  anxiety 
they  now  enjoy.  The  presence  of  symptoms  in  this  patient 
is  in  striking  contrast  to  the  absence  of  symptoms  in  the 
previous  case. 

Case  91. — Displaced  Kidney :  Pyonephrosis :  Operation 
successful. — Mrs.  J.  F.,  aged  34,  was  admitted  into  the  Royal 
Infirmary  on  the  22nd  September.  She  complained  of  pain 
in  the  right  iliac  region,  which  had  lasted  for  three  weeks. 

History  of  Illness. — The  history  obtained  from  the  patient 
was  as  follows  : — The  illness  began  three  weeks  before 
admission  with  pain  in  the  abdomen,  and  she  indicated  the 
right  iliac  region  as  the  site  of  the  pain  ;  the  pain  was  accom- 
panied by  retching  and  vomiting.  These  symptoms  lasted 
for  from  three  to  four  days,  the  vomiting  being  continuous 
during  those  days.  The  pain  was  constant  day  and  night  and 
kept  her  awake  at  night.  It  continued  in  a  mitigated  form 
until  a  few  nights  before  admission,  when  she  got  sudden 
relief  from  it,  and  she  fell  into  a  long  sleep.  She  had  several 
shivering  attacks  which  seem  to  have  been  rigors  ;  she 
sweated  freely  during  the  three  weeks,  and  said  that  her  hair 
was  seldom  dry  during  that  time.  The  seat  of  the  pain  had 
been  tender  to  touch.  There  had  been  a  bearing-down 
sensation  during  micturition,  and  she  stated  that  the  urine 
was  then  thick  and  high-coloured.  She  had  a  similar  attack 
to  that  just  described,  five  years  before. 

She  complained  also  of  pain  in  the  right  lumbar  region 
which  was  always  present ;  this  pain  shot  upwards  to  the 
dorsal  region.  It  came  on  somewhat  gradually,  and  passed 
off  in  Hke  fashion.  The  attacks  of  pain  were  generally  asso- 
ciated with  shivering  or  rigor.  She  had  not  noticed  any 
change  in  the  character  of  the  urine  during  or  after  the  attacks. 

Family  History. — Unimportant. 

Personal  History. — She  was  a  soldier's  wife,  and  had  been 
married  for  thirteen  years,  but  she  had  not  had  any  children. 
She  had  not  been  abroad.  Five  years  before  she  had  a 
very  severe  attack  of  pain  in  the  right  loin  which  lasted  for 
three  days.  During  that  attack  there  was  marked  frequency 
of  micturition. 


310  THE  KIDNEY 

Alimentary  System.— The  appetite  was  usually  good,  but 
the  stomach  was  easily  deranged.  If  she  were  not  careful 
in  diet,  she  suffered  from  pain  behind  the  sternum, 
flatulence,  and  a  sensation  of  weight  in  the  epigastrium. 
The  bowels  only  moved  every  second  or  third  day. 

Abdomen. — The  abdomen  was  of  normal  configuration  ; 
there  was  no  abnormal  bulging  or  retraction.  The  abdominal 
walls  were  well  nourished  and  moved  freely.  There  was 
markedly  greater  resistance  over  the  right  half  of  the 
abdomen,  the  muscles  being  rigid.  This  side  was  tender  on 
pressure  ;  there  was  no  dullness  on  percussion.  On  careful 
palpation  and  gentle  manipulation,  to  allow  the  muscular 
spasm  to  subside,  it  was  ascertained  that  there  was  a  fuUness 
on  the  right  side  which  had  its  lower  limit  at  the  level  of  a 
horizontal  line  drawn  between  the  middle  line  and  the 
anterior  superior  ihac  spine  ;  from  there  it  extended  up- 
wards and  apparently  backwards,  for  a  communicated 
impact  could  be  felt  with  one  hand  pressed  into  the  corre- 
sponding loin.  It  was  not  movable.  The  manipulation  of 
this  body  caused  some  pain. 

The  liver  edge  did  not  extend  below  the  costal  margin. 
The  area  of  spleen  dullness  was  normal.  There  was  no 
gastroptosis.  The  circulatory  and  respiratory  systems  were 
normal. 

The  temperature  was  subnormal,  and  the  pulse  was  beating 
from  76  to  80  per  minute. 

Diagnosis.  —  The  swelling  referred  to  was  somewhat 
soft  and  indefinite,  and  the  question  was,  what  was  it  ? 
It  seemed  to  me  to  be  a  displaced  and  enlarged  kidney,  for 
the  following  reasons  : — (i)  its  position ;  (2)  the  level  of  its 
lower  end  ;  and  (3) ,  most  important  of  all,  the  fact  that  by 
bimanual  palpation  a  communicated  impulse  was  perceptible 
to  the  hand  in  the  loin  by  pressing  on  the  lower  part  of  the 
swelHng  in  the  iliac  region.  The  condition  of  the  urine  threw 
no  Hght  on  the  diagnosis  at  this  stage. 

Progress. — The  temperature  was  taken  every  four  hours 
and  during  the  22nd  and  23rd  it  was  subnormal,  but  on 
the  latter  date  at  9.30  p.m.  the  patient  was  seized  with  a  rigor 


ENLARGEMENT   OF   THE   KIDNEYS  311 

and  the  temperature  rose  to  103-6°  F.  She  had  been  free 
from  pain  until  about  6.30  p.m.  of  the  23rd,  when  there  was 
a  slight  return,  and  it  continued  to  increase  until  about  10  p.m. 
It  was  not  specially  severe  during  the  rigor.  The  pain  was 
confined  to  the  lumbar  region.  The  abdominal  wall  was  very 
tense.  The  pain  passed  off  towards  midnight,  and  the 
temperature  fell  and  reached  97*4°  in  the  early  hours  of  the 
morning.  The  pulse  only  rose  to  90,  while  the  temperature 
was  at  its  highest. 

September  24th. — ^There  was  diffuse  pain  and  tenderness 
on  the  right  side.  The  urine  showed  a  deposit  of  one-eighth 
of  an  inch  of  pus  in  the  urine  glass  ;  there  were  no  blood 
corpuscles.  SHght  pain  continued  all  day  but  became 
worse  towards  the  afternoon,  and  the  temperarure  gradually 
rose  to  103°  and  the  pulse  to  109.  The  abdomen  was  tense. 
There  was  no  rigor. 

September  2jth. — The  temperature  continued  between 
ioi"6°  and  103°.  The  pulse  varied  from  112  to  120.  There 
was  general  abdominal  tenderness.  The  right  side  of  the 
abdomen  was  tense  and  hard,  and  there  was  sUght  bulging. 
Palpation  was  difficult  owing  to  the  tense  and  tender  con- 
dition of  the  part,  but  there  was  a  distinct  increase  in  the 
size  of  the  tumefaction  already  referred  to,  and  the  impact 
to  the  hand  in  the  loin  was  more  marked. 

September  26th. — The  temperature  fell  to  99°,  but  rose 
to  102°  at  night.  She  perspired  freely.  The  general 
tenderness  continued,  but  there  was  no  acute  pain.  She  was 
very  thirsty.  The  pulse  rate  was  about  100.  The  urine 
contained  pus  in  quantity,  but  no  blood. 

The  increase  in  the  size  of  the  sweUing  in  the  right  half  of 
the  abdomen,  extending  into  the  loin,  strengthened  the  view  I 
had  formed  that  the  swelling  was  a  displaced  kidney,  while 
the  appearance  of  pus  in  the  urine  still  further  confirmed  this. 
It  was  evident  that  the  displaced  kidney  was  the  seat  of  an 
acute  pyonephrosis. 

On  the  following  day  the  patient  was  transferred  to 
Professor  Annandale's  ward  with  a  view  to  operation. 
The  swelling  subsided  considerably,  but  in  view  of  the  long 


312  THE   KIDNEY 

history  it  was  decided  to  drain  the  kidney  from  the  loin,  and 
to  fix  it,  if  practicable,  more  in  its  normal  position.  The 
operation  was  performed  by  Professor  Annandale.  The 
organ  was  incised,  and  the  large  sac  formed  by  dilated  pelvis 
and  calices  opened  and  drained,  and  the  organ  was  then 
sutured  to  the  parietes.  The  patient  was  much  benefited  by 
the  operation,  and  left  the  infirmary  relieved  of  pain  and 
discomfort. 

3.  Neoplasm 

Neoplasm  is  the  next  condition,  in  the  organ  under 
consideration,  which  gives  rise  to  enlargement.  Not  in- 
frequently one  or  other  kidney  is  enlarged  by  the  time  the 
physician  or  the  practitioner  sees  the  patient  for  the  first 
time,  or  when  the  abdomen  is  examined  for  the  first  time. 
In  some  instances  there  has  been  an  entire  absence  of 
symptoms  nearly  up  to  the  time  when  the  doctor  is  first 
consulted.  The  complaint  may  then  not  be  more  than  of  a 
feehng  of  discomfort  or  slight  ache  in  the  loin.  There  ma}' 
also  be  a  complaint  of  loss  of  strength  or  of  vigour.  No 
observations  may  have  been  made  regarding  the  appearance 
of  the  urine  and  there  may  have  been  an  entire  absence  of 
discomfort  or  of  appreciable  alteration  in  connection  with 
urination.  By  the  time  the  organ  is  enlarged  examination 
wiU  usually  reveal  the  presence  of  blood  in  the  urine,  visible 
to  the  unaided  eye,  or  to  chemical  or  to  microscopic  examina- 
tion. At  this  early  stage,  if  there  has  been  no  history  of 
pain,  and  no  active  constitutional  disturbance  such  as  is 
present  in  acute  pyelitis,  or  in  tuberculosis,  there  is  unfortu- 
nately no  room  for  doubt  as  to  the  condition  which  is  present. 
Separation  of  the  excretion  from  the  ureters  will  show  that 
the  function  of  the  affected  organ  is  gravely  altered.  It  may 
be  that  blood  in  the  urine  may  be  present  before  there  is 
appreciable  enlargement,  but  I  have  not  seen  such  cases. 
There  can,  however,  be  no  doubt  as  to  the  significance  of 
blood  in  the  urine,  coming  from  one  kidney,  along  with  the 
absence  of  history  of  pain  or  of  acute  illness  referrable  to 
the  urinary  tract. 


ENLARGEMENT   OF  THE   KIDNEYS  313 

The  position  is  as  simple  as  has  been  stated.  An  enlarged 
kidney,  with  an  absence  of  such  history  as  has  been  indicated, 
and  the  presence  of  even  a  small  quantity  of  blood  is  a 
malignant  kidney.  There  is  really  nothing  to  confuse  it 
with,  for  no  other  pathological  change  occurs  with  which  it 
can  be  confused.  One  other  point  may  be  made,  and  that 
is  if  there  is  blood  in  the  urine  and  one  kidney  is  enlarged 
the  kidney  ought  to  be  assumed  to  be  the  source  until  it  is 
proved  not  to  be.  The  prompt  recognition  of  an  enlarged 
kidney  with  blood  in  the  urine  lies  with  the  general  prac- 
titioner in  the  first  instance  ;  and  the  fate  of  the  patient  will, 
in  many  cases,  be  determined  by  him.  In  the  early  stage 
removal  of  the  kidney  may  mean  eradication  of  the  disease  ; 
later  removal  cannot  be  expected  to  have  this  result,  and  the 
judicially  minded  surgeon  may  at  that  stage  advise  against 
operation. 

Illustrative  Cases 

Case  92. — W.  F.,  aged  63,  cutler,  was  admitted  to  hospital 
complaining  of  weakness  and  breath  lessness. 

History. — Two  and  a  half  years  before  admission  he  had 
influenza  and  was  in  bed  for  eleven  weeks.  Since  then  he 
had  suffered  from  breathlessness  and  weakness.  About 
Christmas  time  the  breathlessness  became  so  bad  that  he 
could  hardly  walk  to  work,  although  it  was  only  three  minutes' 
walk  distant.  When  working  at  his  bench  he  used  to  get 
pain  in  the  "  pit  of  the  stomach  "  and  also  between  the 
shoulder  blades.  It  was  a  dull  aching  and  was  relieved  by 
sitting  down.  He  also  had  a  constant  pain  across  the  small 
of  the  back.  He  had  to  give  up  work,  and  had  been  attended 
by  his  doctor,  but  as  he  was  not  improving  he  was  sent  to 
the  Infirmary,  and  was  admitted.  He  had  been  a  heavy 
whisky  and  beer  drinker.  He  was  thin  and  somewhat 
cachetic  looking.  The  pulse  was  70  and  regular,  the  arteries 
were  thickened,  and  the  systoHc  pressure  was  170  mm.  Hg. 
The  heart  sounds  were  faint.  The  lungs  were  emphyse- 
matous, and  there  were  rhonchi  on  both  sides.  On  palpation 
of  the  abdomen  a  mass  was  found  on  the  left  side  evidently 


314  THE   KIDNEY 

an  enlarged  kidney.  The  urine  contained  sufficient  blood  to 
give  it  the  smoky  appearance. 

The  diagnosis  was  bronchitis  mth  emphysema,  a  feeble 
heart  and  sclerosed  vessels ;  and  in  addition  a  maUgnant 
kidney.  Professor  Caird  saw  the  patient,  agreed  with  the 
diagnosis  and  confirmed  the  opinion  that  operation  was  not 
desirable.  Professor  Caird  kindly  separated  the  excretion 
from  the  two  ureters  and  confirmed  the  state  of  the  left 
kidney. 

Cases  of  this  kind  need  not  be  multiphed,  for  the  diagnosis 
is  simple  and  the  treatment  is  hmited  to  surgical  measures. 
For  success  early  recognition,  as  has  been  already  stated, 
is  the  essential  condition.  There  are,  however,  cases  where 
there  is  much  greater  enlargement,  in  which  the  diagnosis  is 
more  complicated.  The  two  follo^^ing  cases  illustrate  this 
on  the  left  side  of  the  abdomen  ;  while  the  third  case  illus- 
trates the  difficulty  on  the  right  side  where  the  question  was 
whether  the  mass  was  formed  bj'  liver  or  kidney. 

Case  93. — Wm.  H.,  aged  23,  in  civil  life  engaged  in  a 
wool  mill.  He  \vas  admitted  to  the  Royal  Infirmary  on  the 
5th  January,  1918.  He  complained  of  pain  on  the  left  side 
in  the  region  of  the  lower  ribs,  extending  upwards  to  the 
shoulder,  and  of  discomfort  after  meals.  The  history 
obtained  from  the  patient  was  as  follows.  He  was  accepted 
for  the  Army  in  September,  1914,  although  he  had  a  shght 
inguinal  hernia.  He  went  to  France  in  the  Scots  Guards  in 
February,  191 5.  In  April  he  was  sent  home  with  the  hernia 
more  developed.  He  was  not  operated  on,  but  had  to  wear 
a  truss  and  returned  to  Belgium  in  August.  At  the  end  of 
'Ma.y,  1916,  he  awoke  one  morning  feeling  unwell.  He  had 
slight  pain  on  the  left  side  and  headache,  but  attached  no 
importance  to  his  sj^mptoms.  He  paraded  for  breakfast  \rith 
his  section,  but  suddenly  fainted  and  later  he  vomited. 
The  battaUon  was  on  rest  at  the  time.  He  was  sent  to  the 
C.C.S.,  and  from  there  to  Boulogne,  where  he  remained  in 
hospital  for  three  weeks  and  was  kept  on  hght  diet.  At  this 
time  there  appears  to  have  been  blood  in  the  urine.  He 
suffered  from  headache.     He  was  sent  to  a  hospital  in  London 


ENLARGEMENT  OF  THE   KIDNEYS  315 

where  he  suffered  from  headache  and  sharp  pain  in  the  small 
of  the  back.  In  October,  1916,  he  felt  much  better  and 
was  sent  to  a  convalescent  camp.  At  this  time,  although  the 
headache  and  pain  in  the  back  were  less,  he  got  breathless  on 
sHght  exertion.  After  a  few  days  he  was  sent  to  a  reserve 
battaUon  and  given  light  duty.  He  was  medically  examined 
several  times  and  discharged  in  December,  1916,  with,  it 
was  stated,  the  diagnosis  of  enlarged  spleen.  He  had  been 
on  full  diet  since  leaving  the  hospital  in  London,  and  was 
feeUng  fairly  well  save  for  the  pains  in  his  side,  which  came 
and  went  irrespective  of  what  he  did  or  what  he  ate.  About 
this  time  he  noticed  a  lump  on  the  left  side  of  the  abdomen. 
He  returned  to  his  native  place  in  Scotland  and  tried  mill- 
work  of  various  kinds,  but  they  all  "  took  too  much  out  of 
him  "  and  he  had  to  give  up  trying  to  work.  The  pain  was 
meanwhile  getting  worse.  By  July,  1917,  the  pains  had 
become  still  worse,  and  he  noticed  there  was  blood  in  the 
urine.  He  consulted  the  doctor,  and  after  some  days  of 
rest  the  red  colour  of  the  urine  disappeared.  He  again 
tried  to  work,  but  had  to  give  it  up.  Since  August,  1917,  the 
pain  in  his  side  had  become  much  worse  and  more  constant ; 
it  was  dragging  in  character.  The  lump  in  his  side  was 
much  larger,  but  it  was  not  painful  when  he  handled  it.  The 
pain  often  prevented  sleep.  In  the  end  of  1917  he  was 
advised  to  go  to  the  Infirmary,  and  he  was  admitted  to  my 
ward  at  the  request  of  the  doctor. 

Condition  on  Admission. — He  was  admitted  on  the  5th 
January,  1918.  The  general  condition  was  fairly  good,  he 
was  6  ft.  I  in.  in  height,  weighed  11  st.  10  lbs.,  but  had  been 
13  St.  12  lbs.  when  he  joined  the  Army.  Pulse,  temperature, 
and  respirations  were  normal.  The  blood  showed  the  red 
corpuscles  to  be  4,180,000,  the  whites  5,600,  the  haemoglobin 
y^  per  cent. ,  and  the  colour  index  0  '95 ;  there  were  no  abnormal 
cells.  The  brachial  pressure  was  142  mm.  Hg.  There  was 
nothing  abnormal  in  heart  or  lungs.  Inspection  of  the 
abdomen  showed  marked  bulging  on  the  left  side  and  this 
side  did  not  move  with  respiration.  On  palpation  a  very 
large  solid  mass  was  felt  extending  from  the  ribs  downwards 


v> 


i6  THE  KIDNEY 


into  the  iliac  region ;  it  filled  up  the  loin  and  at  the 
level  of  the  umbiUcus  extended  i|  ins.  to  the  right  of  the 
mesial  Une.  It  was  dull  on  percussion,  the  duU  note  extending 
to  the  seventh  rib  in  the  axiUary  hne.  The  surface  of  the  mass 
was  smooth.  It  was  closely  in  contact  with  the  parietes. 
It  had  a  definite  sharp  edge,  the  hne  of  which  was  broken  by 
a  notch.  Pain  was  complained  of  when  the  mass  was 
pressed  between  one  hand  in  front  and  the  other  in  the  loin. 
Sixty-five  ounces  of  urine  were  passed  in  twenty-four  hours, 
the  specific  gravity  was  1027,  there  was  a  small  amount  of 
albumin,  the  total  urea  for  twenty-four  hours  was  604 '5  grains. 
Pain  was  constantly  present.  The  patient  was  easier  lying  on 
the  right  side.  The  appetite  was  good,  but  if  he  took  a  large 
meal  he  had  discomfort ;  and  if  the  bowels  were  not  acting 
the  pain  became  worse  ;  a  purgative  always  gave  rehef . 
The  mass  increased  in  size  and  gave  rise  to  increasing  dis- 
confort,  with  a  feeUng  of  great  weight ;  and  he  was  kept 
awake  at  night  by  pain. 

Remarks. — This  patient  came  to  hospital  with  a  diagnosis, 
seemingly  passed  on  from  hospital  to  hospital,  of  enlarged 
spleen  ;  and  the  medical  man  attending  him  after  he  was 
discharged  did  not  challenge  the  diagnosis.  There  was  also 
a  history  of  haematuria.  When  first  seen  and  the  abdomen 
examined  it  was  easy  to  accept  the  proposition  that  the  mass 
was  a  huge  spleen  ;  it  extended  up  under  the  ribs  as  a  large 
spleen  extends  ;  its  shape,  smooth  surface,  somewhat  sharp 
anterior  edge,  and  the  notch  in  the  edge  aU  contributed  to  this 
fallacy.  There  was  little  doubt  that  the  mass  was  mahgnant, 
although  I  had  never  seen  a  mahgnant  spleen  of  such  large 
size.  The  left  kidney  was  practically  functionless,  but 
even  this  was  not  absolute  proof  that  the  mass  was  kidney, 
for  we  knew  that  a  big  spleen  might  press  upon,  flatten  and 
destroy  the  kidney  as  an  excretory  organ.  Professor  Caird 
saw  the  patient  several  times.  We  both  recognized  the 
gravity  of  removing  a  spleen  of  this  size,  and  yet  operation 
seemed  imperative  unless  the  patient  were  left  to  suffer  and 
to  die.  The  patient  was  anxious  that  something  should  be 
done  for  his  rehef  and  was  wilHng  to  face  the  risk.     Professor 


ENLARGEMENT  OF  THE   KIDNEYS  317 

Caird  went  into  the  history  again  and  came  to  the  conclusion 
that  it  was  kidney.  This  was  confirmed  when  the  abdomen 
was  opened  and  the  mass  was  removed  without  very  great 
difficulty.  It  was  as  we  expected  malignant.  The  patient 
stood  the  operation  remarkably  well  and  he  made  an  excellent 
recovery.  In  the  summer  of  1919,  however,  it  was  reported 
that  the  abdomen  had  become  widely  affected. 

Case  94. — W.  P.,  a  girl  16  years  of  age,  was  admitted  to 
my  ward  on  the  19th  May,  191 9.  The  complaint  was  pain 
and  swelling  on  the  left  side  of  the  abdomen.  The  history 
was  that  about  the  end  of  February  or  the  beginning  of 
iMarch  she  began  to  be  troubled  with  pain  on  the  left  side. 
It  did  not  come  on  at  any  definite  time,  but  most  frequently 
it  came  on  when  she  had  been  standing  for  some  time  at  her 
work.  She  was  a  grocer's  assistant.  She  had  attacks  of 
severe  pain  from  time  to  time  which  lasted  two  or  three 
days.  The  pain  was  reheved  by  sitting  down  ;  but  Ipng 
dovm  on  the  left  side  was  more  effective  in  giving  rehef. 
After  these  attacks  she  would  be  free  of  pain  for  a  fortnight. 
On  Monday,  the  12  th  May,  when  trjdng  on  a  dress,  her  sister 
noticed  a  swelling  "  over  the  stomach."  She  was  sent  to  the 
doctor,  who  advised  her  to  go  to  the  Infirmary.  She  was 
seen  on  the  surgical  side,  and  sent  over  to  my  ward  for 
observation. 

Examination. — The  patient  was  a  healthy-looking  girl 
with  a  ruddy  complexion  and  pleasant  expression.  She  was 
well  nourished.  She  had  menstruated  once,  a  year  before 
admission.  On  inspection  the  abdomen  showed  marked 
bulging  in  the  epigastrium  extending  towards  the  left  flank. 
On  palpation  a  large  mass  was  felt  extending  from  the  right 
costal  margin  2  ins.  from  midhne  to  |  in.  below  the  um- 
biUcus,  then  in  a  straight  hne  to  the  left  and  then  upwards 
in  the  direction  of  the  posterior  axillary  line.  It  was  tender 
on  pressure  along  its  anterior  margin.  The  percussion  note 
over  it  was  dull  and  the  dullness  was  continuous  mth  the 
Uver  dullness  to  the  right.  The  hmits  of  dullness  and  the 
area  defined  by  palpation  are  shown  in  Fig.  35,  marked  N. 
The  urine  deposited  urates  but  contained  no  albumin.    Blood 


3i8  THE  KIDNEY 

examination  showed  slight  impoverishment  in  haemoglobin, 
and  gave  a  leucocyte  count  of  15,000  mth  67  per  cent,  of 
polymorphs  ;  later  a  differential  count  gave  50  per  cent,  of 
pol3'morphs,  35  per  cent,  of  lymphocytes,  and  15  per  cent,  of 
larger  mononuclears.  During  the  first  days  in  hospital 
she  had  no  pain  and  slept  and  ate  well.  The  mass  increased 
in  size  rapidly.  The  separator  was  used  and  showed  marked 
deficiency  in  the  excretion  from  the  left  ureter.  On  the  3rd 
June  pain  was  very  severe  over  the  abdomen  and  small  of 
back  ;  the  mass  had  further  increased  in  size ;  the  circum- 
ference of  the  abdomen  where  it  projected  most  was 
29!  ins.  A  rise  of  temperature  of  from  i  to  3  degrees 
was  present  for  a  week.  She  became  pale  and  collapsed, 
suggesting  that  haemorrhage  had  taken  place  into  the  mass. 
Pain  was  relieved  by  means  of  herom  given  hypodermically. 
Her  condition  continued  to  be  critical  for  some  days.  By 
the  14th  June  pain  subsided  so  that  only  a  small  dose  of 
heroin  or  morphine  was  required  to  ensure  comfort.  The 
mass  was  tender  in  its  upper  part,  and  the  circumference  of 
the  abdomen  measured  31  ins.  From  this  time  onward  there 
was  an  abeyance  of  symptoms  ;  her  general  condition  steadily 
and  markedly  improved,  her  colour  became  ruddy,  her  cheeks 
filled  up,  and  she  expressed  herself  as  feehng  quite  well. 
The  mass  became  less,  and  it  became  a  question  as  to  what 
was  to  be  done.  Was  there  to  be  surgical  intervention  ? 
The  separator  was  used  again,  early  in  August,  and  the  fluid 
obtained  from  each  ureter  carefully  and  fully  examined  in 
the  Department  of  CHnical  Pathology.  The  amount  of 
fluid  from  the  left  ureter  was  much  smaller  than  from  the 
right.  The  fluid  from  the  latter  showed  nothing  abnormal ; 
the  fluid  from  the  left  ureter  contained  a  few  red  corpuscles,  a 
few  pol3nTiorphs,  and  a  small  amount  of  albumin.  No  micro- 
organisms were  shown  on  microscopic  examination  or  on  cul- 
ture. A  differential  leucocyte  count,  in  a  leucocytosis  of  10,000 
gave  pol^anorphs  40  per  cent.,  small  l5miphocytes  36  per 
cent.,  large  lymphocytes  20  per  cent.,  eosinophiles  3  per  cent. 
Discussion  and  Conclusions. — Both  these  cases  were  ex- 
amined and  re-examined  and  discussed  with  my  students 


ENLARGEMENT  OF  THE   KIDNEYS  319 

freely.  In  the  first  place  it  was,  of  course,  apparent  that  in 
both  cases  there  was  a  mass  in  the  abdomen  that  could  not 
be  overlooked  by  the  veriest  t3a'0.  The  next  question  was 
not  what  was  the  character  of  the  mass  ?  but,  what  organ 
had  given  rise  to  it  or  in  which  of  the  abdominal  organs  had 
it  developed  ?  The  importance  of  this  being  made,  the  next 
question  will  presently  appear.  In  the  first  of  the  two  cases 
the  patient  came  with  a  diagnosis  of  enlarged  spleen,  and 
from  external  examination  of  the  abdomen  there  seemed  to 
be  no  reason  to  question  it.  The  mass  was  extraordinarily 
Uke  a  greatly  enlarged  spleen.  The  blood  revealed  no  change 
in  its  constituents  beyond  a  slight  anaemia.  There  was, 
however,  the  history  of  blood  in  the  urine  the  day  he  fainted 
on  parade.  This  point  in  the  history  of  this  and  of  other 
cases  nust  be  regarded  as  of  prime  importance.  In  this  case 
a  diagnosis  of  enlarged  spleen  seemed  to  have  been  reached 
early,  but  it  is  to  be  noted  that  this  "  enlarged  spleen  "  was 
associated  with  haematuria  which  probably  led  to  his  being 
carefully  and  sparingly  dieted  when  in  hospital.  It  was  at 
this  stage  the  mistake  in  the  diagnosis  originated,  and  it  was 
due  to  mistaking  a  big  kidney  for  a  big  spleen.  Whatever 
difficulties  the  later  history  of  a  case  of  this  kind  presents 
it  must  be  insisted  on  that  at  the  early  stage  such  a  mistake 
is  no  longer  inevitable  and  therefore  it  ought  not  to  be  made. 
Confirmation  of  the  diagnosis  can  be  obtained  by  the  use  of 
the  separator.  In  the  advanced  stage  at  which  we  first  saw 
this  patient  the  problem  presented  itself  of  spleen  versus 
kidney,  and  the  warning  has  already  been  made  as  to  the 
great  resemblance  an  enlarged  kidney  may  offer  to  enlarged 
spleen.  Personally,  I  and  others  laid  too  much  stress  on  the 
resemblance  both  as  regarded  position  and  configuration. 
The  value  of  the  separator  must  be  emphasized,  especially 
when  there  is  a  history  of  early  hsematuria,  as  was  obtained 
from  this  patient.  At  the  outset  the  difficulty  in  regarding 
the  mass  as  splenic  was  that  malignant  disease  of  the  spleen 
was  usually  secondary,  and  that  it  did  not  attain  such  an 
extraordinary  size.  Except  mahgnant  growth  there  was  no 
other  conceivable  change  which   could  give  rise  to   such 


320  THE   KIDNEY 

enlargement.  The  great  lesson  illustrated  by  the  experience 
of  this  case  was  that  a  mass  in  this  region  is  almost  certainly 
of  renal  origin,  and  that  the  result  obtained  by  the  separator 
may  be  taken  as  conclusive  evidence  against  a  splenic 
tumour.  The  region  of  the  loin  belongs  clinically  and 
pathologically  to  the  kidney,  not  to  the  spleen. 

The  second  case,  that  of  the  girl  aged  i6  (Case   94),  was 
not  seen  by  a  medical  man  until  the  mass  had  attained  a 
great  size.     She  was  under  observation  in  hospital  within 
a  week,  and  as  soon  as  she  was  seen  and  examined  the 
question  again  was  :  Which  organ  is  this  ?     The  external 
examination  suggested  left  lobe  of  hver  and  perhaps  spleen 
as  well.     At  first  the  kidney  seemed  to  be  excluded.     The 
mass  was  regarded  as  a  rapidly  advancing  sarcoma  not 
suitable  for  operation.     There  was  no  history  to  help  ;  there 
had  been  no  S5miptoms  of  any  kind.     It  may  be  that  the 
history  of  a  single  menstruation  a  year  before  was  a  mistake  ; 
that  it  may  have  been  a  temporary  hsematuria  and  a  mani- 
festation of  the  early  stage  of  the  malady.     Hsematuria  may 
be  an  early  manifestation  of  malignant  disease  in  the  kidney 
and  is  often  the  first  symptom  to  attract  attention.     In 
this  patient  the  rapid  growth  of  the  mass  was  very  striking, 
and  the  collapse  which  occurred  soon  after  her  admission 
seemed  so  definitely  to  be  due  to  large  haemorrhage  into  a 
rapidly  advancing  sarcoma  that  there  was  no   thought   of 
operation.     She,  however,  rallied  from  this  attack  and  the 
mass  shrank  somewhat.     The  general  condition  improved 
so  much  that  it  challenged  the  diagnosis  of  sarcoma.     The 
improvement  again  raised  the  question  as  to  which  organ 
was  affected.     The  separator  was  again  used  with  the  result 
already  mentioned.     She  was  also  examined  by  means  of 
X-rays.     The  result  of  this  examination  left  no  doubt  that 
we  had  to  do  \Aith  a  renal  tumour,  in  spite  of  the  extraordinary 
resemblance  of  the  mass  to  a  greatly  enlarged  hver.     The 
extraordinary   picture   presented   by   the   position   of   the 
stomach  as  revealed  by  bismuth  is  shown  in  Fig.  35,  taken 
by  Dr.  Hope  Fowler.     The  fundus  containing  air  and  marked 
F  is  in  its  normal  position,  while  the  body  marked  S  is 


FiG.''35- — Case  94.  N,  neoplasm;  F,  fundus  of  stomach  containing  air; 
S,  stomach  containing  bismuth;  P,  pylorus;  L,  liver;  I,  small  in- 
testine full  of  bismuth  ;   U,  umbilicus. 

[To  face  page  320. 


ENLARGEMENT  OF  THE  KIDNEYS  321 

stretched  above  the  upper  border  of  the  mass  and  down  its 
right  border  to  end  in  P,  the  pylorus.  The  liver  is  marked  L, 
while  I  shows  the  small  intestine  pushed  into  a  clump  and 
containing  bismuth.  N  marks  the  neoplasm,  and  U  the 
umbilicus.  Operation  was  agreed  to  by  the  parents.  The 
operation  was  performed  by  Mr.  Wade.  It  was  exceedingly 
difficult,  but  the  patient  soon  raUied  from  the  shock  of  it,  and 
recovered  sufficiently  to  be  able  to  return  home.  The 
mass  was  a  malignant  kidney. 

This  case  further  strengthens  the  opinion  already  ex- 
pressed that  the  result  of  observation  made  by  means  of  the 
separator  is  of  leading  importance  in  difficult  cases  in  deter- 
mining which  organ  is  affected  ;  and  that,  when  the  function 
of  the  kidney  is  so  gravely  involved  as  it  was  in  these  two 
cases,  the  diagnosis  of  Iddney  lesion  becomes  inevitable.  In 
the  case  of  the  girl  the  radiographic  plate  was  conclusive 
that  the  mass  was  kidney,  and  for  the  following  reasons — 
first,  the  fundus  of  the  stomach  would  have  been  com- 
pressed to  the  right  by  a  large  spleen,  and  to  the  left  and 
downwards  by  an  enlarged  left  lobe  of  the  hver,  whereas  it 
was  above  the  mass,  occupied  its  normal  position,  and  was 
not  lessened  in  capacity ;  second,  the  body  of  the  stomach 
was  stretched  out  over  the  upper  hmit  and  down  the  right 
limit  of  the  mass  as  it  could  not  have  been  were  the  mass 
hepatic  in  origin. 

Again  it  may  be  repeated  that  the  question  of  diagnosis, 
even  in  such  cases  as  have  been  described,  Hes  between  the 
three  organs  indicated.  A  mass  in  this  part  of  the  abdomen 
never  arises  from  any  other  structure  or  tissue  or  organ. 
When  this  is  fully  accepted  the  way  to  correct  diagnosis  is 
greatly  simplified,  and  in  the  great  majority  of  cases  is 
comparatively  eas}^  if  reasonable  skill  in  the  examination  of 
the  abdomen  has  been  acquired. 

The  Right  Kidney 

All  the  conditions  akeady  dealt  with  occur  on  either  side, 
but  on  the  right  the  question  lies  between  hver  and  kidney 

21 


322  THE   KIDNEY 

instead  of  spleen  and  kidney  as  is  the  case  on  the  left.     The 
right  kidney  is,  more  commonly  than  the  left,  movable  or 
floating  and  difficulty  arises  more  commonly  on  this  side. 
A  displaced  fixed  kidney  may  be  mistaken  for  a  hver  swelling 
or  for  gall-bladder ;   and  a  distended  gall-bladder  has  been 
diagnosed  as  kidney.     The  real  difficulty  is  between  kidney 
and  right  lobe  of  hver.     A  palpable  swelling  in  the  loin, 
palpable  bimanually,  may  be  either.     The  difficulty  arises 
usually  in  mahgnant  disease,  for  mahgnant  disease  may  give 
rise  to  a  mass  projecting  from  the  under  surface  of  the  right 
lobe  and  very  suggestive  of  enlarged  kidne}/ ;   while  on  the 
other  hand  an  enlarged  kidney  may  suggest  the  right  lobe 
of  the  Hver.     The  history  often  helps  in  forming  a  correct 
opinion.     If  there  is  any  doubt,  the  use  of  the  separator  will 
settle  the  point.     In  the  great  majority  of  cases  no  serious 
difficulty  arises,  but  cases  occur  in  which  diagnosis  is  difficult. 
Some  years  ago  1  saw  in  consultation  a  man  who  had  spent 
his  working  days  in  India.     There  was  a  mass  in  the  upper 
right  segment  of  the  abdomen.     He  had  been  seen  by  more 
than  one  consultant  in  London,  and  had  been  examined  by 
means  of  radiography.     There  had  evidently  been  a  difference 
of  opinion,  but  he  came  down  to  Scotland,  with  a  strong 
diagnosis   of  cystic  growth  in  the  hver.     There  was   an 
absence  of  urinary  symptoms  ;  he  had,  however,  lost  weight 
and  deteriorated  in  strength.     On  examination  there  was 
a  large  mass  fiUing  up  the  loin,  readily  palpable  in  front  as 
well  as  bimanually  and  which  in  parts  had  the  resiUency 
of  a  cyst.     If  it  were  a  cyst  and  in  the  Hver,  as  had  been 
strongly  insisted  on,  it  could  only  be  a  hydatid  cyst,  and 
hydatid  cyst  could  be  dealt  with  surgicaUy.     At  a  later 
conference  with  Mr.,  now  Sir  Harold,  Stiles  it  was  agreed 
that  the  mass  was  renal  and  not  hepatic ;    that  it  was  a 
cystic  sarcoma  and  inoperable.     At  that  time  the  value  of 
the  separator  had  not  been  estabHshed ;    but  it  is  evident 
that  its  use  in  this  patient  would  have  saved  much  difference 
of  opinion,  and  if  used  early  would  have  been  of  vital  value  to 
the  patient.     The  case  is  given  here  to  iUustrate  the  kind  of 
difficulty  which  confronts  the  practitioner  and  the  consultant. 


ENLARGEMENT  OF  THE   KIDNEYS  323 

The  following  case  represents  another  difficulty  in  this 
region.  A  patient,  seen  with  Dr.  Hunter,  whose  general 
condition  had  deteriorated,  and  who  had  lost  weight,  was 
believed  to  have  mahgnant  disease  of  the  liver.  There  was 
a  swelling  in  the  right  loin  with  some  pain  on  pressure,  the 
temperature  had  risen,  and  there  was  friction  at  the  lower  part 
of  the  right  lung.  It  seemed  possible  to  explain  the  symptoms 
and  the  signs  by  regarding  the  swelling  as  perinephric  and 
inflammatory  with  a  secondary  involvement  of  the  pleura. 
The  diagnosis  of  mahgnant  Hver  could  not,  however,  be 
set  aside  in  view  of  the  skill  and  care  with  which  the  case 
had  been  watched.  Yet  suclra  febrile  attack  as  was  running 
when  I  saw  the  patient  seemed  not  to  be  satisfactorily 
explained  by  pleural  metastasis  from  the  hver.  The  patient's 
friends  were  anxious  that  any  operative  measures  thought  of 
should  be  adopted,  and  the  patient  was  Hke-minded.  He  was 
accordingly  sent  into  Edinburgh  to  Professor  Alexis  Thomson. 
He  leant  to  the  mahgnant  hver  view,  but  recognized  the 
importance  of  the  symptoms  which  had  emerged.  The 
abdomen  was  opened  and  the  sweUing  in  the  loin  was  found 
to  be  the  right  lobe  of  the  hver  showing  mahgnant  masses 
on  its  under  surface.  The  patient  recovered  from  the 
operation,  and  although  no  benefit  accrued,  every  one  con- 
cerned was  satisfied  that  everything  possible  had  been  done. 

This  case  is  referred  to  as  it  illustrates  a  principle  which 
sometimes  serves  as  a  guide  in  deciding  what  advice  is  to  be 
given.  It  is  this,  namely,  that  if  after  careful,  fuU  and 
skilful  examination  there  is  a  loophole  of  hope  that  a  diagnosis 
may  be  wrong,  or  if  the  opinion  between  two  conditions  is 
balanced  fairly  evenly,  the  patient  ought  to  be  informed  of 
the  doubt  and  be  given  the  option  of  operation  or  of  no 
operation. 


CHAPTER   XXVII 

BACILLUS   COLI   INFECTION    OF  THE   URINARY  TRACT 

This  is  one  of  the  most  important  of  the  infective  conditions 
occurring  in  the  abdomen.  Its  place  as  a  clinical  entity  is 
of  comparatively  recent  date  ;  and  this  may  be  taken  as  the 
explanation  of  the  fact  that  it  is  not  always  diagnosed,  nor 
even  thought  of.  Like  other  infective  conditions  the 
symptoms  vary  wdthin  somewhat  wide  hmits.  Attention 
may  be  directed  early  to  the  urinary  tract  by  the  patient's 
complaint  of  frequency  of  micturition,  of  some  discomfort 
before,  during,  or  after  micturition,  and  by  statements  made 
regarding  the  appearance  of  the  urine.  Examination  of  the 
urine  may  reveal  the  presence  of  albumin  and  blood,  and  the 
case  be  diagnosed  as  one  of  nephritis.  In  some  of  these 
cases  the  temperature  is  raised  several  degrees  and  there  may 
be  a  history  of  shivering  or  rigor.  A  temperature  degrees 
above  normal,  rigor,  blood  in  the  urine,  and  no  puffiness  of 
the  face  indicate  urinary  infection  and  not  Bright's  disease. 
In  other  cases  there  is  no  complaint  made  which  directs 
attention  to  this  tract,  and,  as  a  consequence,  questions  are 
not  asked  which  have  any  relation  to  it,  and  the  true  nature 
of  the  case  is  entirely  missed. 

\Vhen  knowledge  of  the  phases  of  the  malady  is  more 
universal  than  it  seems  to  be,  failure  to  recognize  its  presence 
wiU  lessen.  A  malady  cannot  be  diagnosed  if  it  is  not  in- 
cluded among  the  possibihties.  And  it  is  of  high  importance 
that  this  infection  should  occupy  a  more  definite  place  in 
general  practice  than  it  apparentl}'^  does. 

It  occurs  at  aU  ages,  and  it  may  be  fatal  at  any  period  of 
life. 

324 


BACILLUS  COLI   INFECTION  325 

In  the  cases  briefly  reported  at  the  end  of  this  chapter  the 
occurrence  of  the  malady  in  a  comparatively  mild  form  in 
children  is  illustrated.  They  show  that  the  condition  can 
be  easily  overlooked  in  them. 

In  adults  one's  experience  is  the  same.  An  adult  suffering 
from  this  infection  was  diagnosed  as  a  "  recurring  gastritis  ' ' 
because  of  abdominal  pain  and  vomiting.  There  was  no 
evidence  of  gastric  or  intestinal  malady,  but  recurring  rise 
of  temperature  and  a  swelling  in  the  right  loin  at  once 
suggested  a  bacillus  coli  infection  of  the  urinary  tract,  which 
led  to  a  bacteriological  examination  of  the  urine  and  the 
estabhshment  of  the  diagnosis.  Another  adult,  thought  to 
be  suffering  from  "  acute  nephritis,"  presented  phenomena 
which  one  knew  could  not  be  caused  by  acute  Bright 's 
disease  ;  and  this  knowledge,  combined  with  the  fact  that 
certain  definite  phenomena  were  present,  made  it  practically 
certain  that  the  patient  was  suffering  from  an  acute  baciUary 
infection  of  the  urinary  tract.  Bacteriological  examination 
of  the  urine  established  the  diagnosis,  and  led  to  treatment 
with  an  autogenous  vaccine  which  was  highly  effective. 
Some  time  ago  I  was  asked  to  see  a  patient  who  was  thought 
to  have  pneumonia  ;  she  was  running  a  high  temperature, 
had  indefinite  phenomena  in  the  limgs,  and  was  semi- 
comatose. Examination  of  the  chest  only  revealed  bronchial 
catarrh  with  evidence  of  adherent  pleura  on  one  side.  The 
condition  did  not  suggest  to  my  mind  pneumonia.  On 
examination  of  the  abdomen  I  found  the  right  kidney  to  be 
enlarged  and  painful.  I  advised  a  bacteriological  examination 
of  the  urine  as  the  case  was  probably  one  of  baciUary  infection. 
This  suggestion  was  found  to  be  correct.  Quite  recently  I 
was  asked  to  see  a  patient  who  had  been  confined  to  bed  for 
weeks  Avith  recurring  attacks  of  periods  of  high  temperature, 
the  cause  of  which  had  not  been  determined.  Examination 
of  the  chest  revealed  nothing  abnormal  in  heart  or  lungs. 
On  examination  of  the  abdomen  the  right  kidney  was  found 
to  be  enlarged  and  tender  ;  a  baciUary  infection  involving 
the  pelvis  of  the  kidney  as  the  cause  of  the  recurring  pjTexia 
was  suggested.     A  bacteriological  examination  of  the  urine 


326       THE   KIDNEY   AND   URINARY   TRACT 

showed  this  suggestion  was  correct ;  the  patient  was  treated 
by  urotropin  and  citrate  of  potash,  Mith  the  result  that  the 
recurring  pyrexia  was  stopped. 

Illustrative  Cases 

Case  95. — Mary  G.,  aged  i6,  was  admitted  on  the  29th 
October,  1917.  The  child  was  sent  to  hospital  without  a 
diagnosis.  She  was  ill  and  had  a  temperature  running  between 
normal  and  100 "8°  F.  On  the  2nd  November  the  temperature 
rose  above  this  hmit,  and,  in  view  of  the  absence  of  discover- 
able lesion  in  the  thorax,  the  urine  was  fully  investigated. 
It  contained  pus  in  small  quantity  and  was  swarming  v\dth 
baciUus  coli.  She  was  given  urotropine  and  later  citrate  of 
potash.  On  the  3rd  November,  the  temperature  reached 
104°,  but  by  the  7th  it  became  normal  and  remained  normal 
until  she  was  discharged  on  6th  December  completely 
recovered. 

Case  96. — Pat.  G.,  aged  9  years,  was  admitted  on  the 
26th  Februar}/,  1918,  as  a  case  of  hsematuria  due  to  nephritis. 
The  urine  was  found  to  contain  not  only  blood  but  pus  and 
bacillus  coli.  He  was  treated  by  urotropine  and  citrate  of 
potash  ;  and  was  discharged  cured  in  April.  In  this  patient 
there  were  no  symptoms.  Three  months  before  admission, 
his  mother  had  noticed  that  the  urine  was  red  in  colour,  and 
took  him  to  the  doctor.  He  had  been  treated  and  not 
allowed  to  go  to  school.  The  red  colour  of  the  urine  came  and 
disappeared  several  times  before  the  child  was  sent  to  the 
Infirmary.  There  had  been  no  complaint  of  any  kind  and 
the  boy  appeared  to  be  quite  well. 

Case  97. — Barbara  H.,  aged  9,  was  admitted  on  the  20th 
August,  1918,  as  a  case  of  Bright's  disease.  The  face  was 
puffy  and  there  was  albumin  in  the  urine.  This  patient  was 
also  found  to  have  a  bacillus  coU  infection.  The  temperature 
rose  to  101°  and  102 '8°.  She  was  treated  by  hexamine  and 
a  bacillus  coli  vaccine  and  made  a  complete  recovery. 

Case  98. — Mr.  S,,  aged  60,  was  seen  in  consultation.  He 
had  been  on  holiday  for  a  few  weeks  and  had  been  in  his 


BACILLUS   COLT    INFECTION  327 

usual  state  of  health.  The  first  symptom  he  observed  was 
increased  frequency  of  micturition,  which  persisted  for  some 
days  and  was  a  new  experience  for  him.  After  a  few  days 
of  this  he  suddenly  began  to  feel  chilly  and  unwell,  and  this 
was  followed  by  a  definite  rigor  and  a  rise  of  temperature  to 
104°  and  105°.  He  returned  home,  and  was  seen  by  his 
medical  attendant.  The  frequency  of  micturition  continued, 
and  became  very  troublesome.  The  temperature  ranged  daily 
from  normal  to  104°.  The  urine  contained  blood,  some  pus, 
and  urates.  He  was  thought  to  be  suffering  from  acute 
nephritis.  The  condition  pointed  so  clearly  to  an  infection 
by  bacillus  coli  that  I  suggested  having  the  urine  examined 
and,  if  the  diagnosis  was  correct,  that  an  autogenous  vaccine 
should  be  prepared.  The  patient's  temperature  was  speedily 
controlled  by  the  vaccine,  and  in  due  time  complete  recovery 
followed,  and  the  bacillus  could  no  longer  be  grown  from  the 
urine. 

Case  99. — Mrs.  McB.,  aged  56,  was  admitted,  as  a  re- 
curring gastritis,  to  \¥ard  27  on  Tuesday,  August  23rd,  igio. 
The  history  obtained  from  her  was  that  she  was  well  until 
six  weeks  before  admission.  The  first  symptoms  were  pains 
in  the  knees  and  legs  ;  but  more  severe  pain  in  the  lower  part 
of  the  abdomen  (the  hypogastrium) ,  the  pain  there  being 
continuously  present  although  the  severity  varied.  She  felt 
hot  and  perspired  freely  at  that  time,  but  did  not  vomit. 
Her  doctor  saw  her  and  kept  her  in  bed  for  eight  days.  About 
a  fortnight  after  this  patient  had  another  attack  of  the  same 
kind,  save  that  the  pain  was  more  definitely  abdominal  in 
situation,  and  with  the  pain  there  was  vomiting.  The  vomited 
matter  was  green  in  colour  and  the  vomiting  came  on  after 
taking  food.  She  felt  very  hot  and  perspired  freely  during 
this  attack  also.  A  fortnight  after  this  she  was  able  to  be 
out  of  bed.  On  Saturday,  the  20th,  three  days  before 
admission,  when  attending  to  her  household  duties  in  the 
forenoon,  she  felt  chilly  and  shivered  ;  pain  came  on  in  the 
abdomen,  being  again  most  marked  in  the  hypogastric 
region  ;  she  vomited  ;  and  headache  developed. 

Her  doctor  kindly  gave  us  the  information  that,  during 


328       THE   KIDNEY   AND    URINARY   TRACT 

the  six  weeks  referred  to  in  the  history  obtained  from  the 
patient,  there  had  been  three  acute  attacks,  characterized 
by  abdominal  pain,  usually  vomiting,  and  a  temperature 
reaching  104°  F.  in  twenty-four  hours,  and  continuing  raised 
for  about  eight  days. 

Such  was  the  histor^r  of  the  patient's  illness  up  to  the  time 
ot  admission  to  the  Infirmary. 

On  admission  she  complained  of  abdominal  pain.  The 
pain  was  sometimes  referred  to  the  left  h3rpochondrium, 
sometimes  passing  round  the  right  hjrpochondrium  to  the 
back,  while  at  other  times  it  was  most  marked  in  the  hypo- 
gastrium  with  a  feehng  of  distension  in  this  region.  A^omiting 
occurred  if  she  took  food.  The  vomit  was  greenish  in  colour. 
She  also  complained  of  headache.  The  pulse  was  107,  the 
respirations  32,  and  the  temperature  100"^  on  admission, 
and  101°  in  the  evening. 

On  examination  of  the  abdomen  it  was  noted  that  there 
was  no  rigidity  of  the  abdomen  save  slightly  of  the  right 
rectus.  There  was  no  tenderness.  There  was  a  swelling 
in  the  right  lumbar  region.  On  being  questioned  the  patient 
stated  that  she  had  difficulty  in  micturition  at  times  ;  that 
there  was  a  frequent  desire  to  micturate  ;  that  there  was 
pain  during  and  after  micturition  ;  and  often  a  feeling  of 
distension  in  the  region  of  the  bladder.  The  swelling  in  the 
right  lumbar  region  was  clearly  the  right  kidney,  enlarged 
but  not  tender.  On  examination  of  the  urine  it  was  found 
to  contain  pus,  and  on  microscopic  investigation  showed 
not  only  pus  cells,  but  granular  and  hyaline  casts.  The  blood 
gave  a  count  of  21,000  leucocytes — the  leucocytosis  being 
polymorphonuclear. 

The  temperature  rose  above  normal  for  the  first  four  days 
but  then  fell  to  normal  and  subnormal.  There  was  a  copious 
deposit  of  pus  in  the  urine  ;  the  swelling  in  the  lumbar  region 
became  smaller  and  more  definite  in  outhne.  She  was  in 
this  condition  when  I  first  saw  her.  The  kidney  was  large, 
displaced  considerably  do\Miwards,  and  sHghtly  tender, 
A  catheter  specimen  of  the  urine  was  obtained  and  sent  to 
the  pathological  department  for  cultural  investigation.      I 


BACILLUS   COLI   INFECTION  329 

had  little  doubt  that  the  case  would  turn  out  to  be  one  of 
coliuria.  The  pus  in  the  urine,  the  three  attacks  of  fever,  and 
the  pain  in  the  bladder  all  pointed  to  that  conclusion.  The 
condition  of  the  right  kidney  could  be  explained  on  the 
assumption  that  there  had  previously  existed  a  displaced 
and  movable  kidney,  the  pelvis  of  which  had  become  infected 
from  the  bladder,  and  that  owing  to  a  change  in  the  axis 
of  the  organ,  or  to  blockage  of  the  ureter  by  purulent  exudate, 
a  pyonephrosis  had  been  determined.  When  the  ureter 
became  patent  again  the  pus  escaped,  and  the  swelling 
rapidly  subsided.  The  kidney  retreated  into  its  normal 
position  in  the  loin,  so  that  ultimately  only  its  lower  pole 
was  palpable  as  the  patient  lay  in  bed.  The  cultural  report 
was  that  a  pure  culture  of  bacillus  coU  had  been  obtained 
from  the  catheter  specimen  sent  for  examination. 

The  treatment  consisted  in  administering  10  grs.  each  of 
potassium  citrate  and  potassium  acetate  every  four  hours 
until  the  urine  was  rendered  alkaUne,  and  then  less  frequently, 
but  in  sufficient  quantity  to  keep  the  urine  alkahne.  To  this 
urotropin  gr.  x.  were  added  three  times  a  day.  The  pus 
speedily  disappeared  from  the  urine  and  also  aU  trace  of 
albumin.  As  she  complained  of  some  pain  apparently  in 
the  urethra  the  urotropin  was  stopped  and  some  tincture 
of  hyoscymus  given  as  a  sedative.  The  patient  made  a 
complete  recovery. 

Treatment. — The  treatment  of  the  condition,  when  it  is 
recognized  is  well  known  and  need  not  be  discussed  here. 
I  may,  however,  state  that  my  experience  of  treatment  by 
means  of  autogenous  vaccine  has  been  most  satisfactory ; 
but  it  has  sometimes  to  be  used  in  large  doses. 


PRINTED     BY    WILLIAM   CLOWES    AND    SONS,    LIMITED,    BECCLES,    FOR 

BAILLIERE,    TINDALL  AND    COX 

8,    HENRIETTA   STREET,    COVENT    GARDEN,    LONDON,    W.C.2 


COLUMBIA    UNIVERSTTV   , 

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